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Non-Incineration

Medical Waste

Treatment Technologies

in Europe

A Recource for Hospital Administrators,

Facility Managers, Health Care Professionals,

Environmental Advocates, and

Community Members

June 2004

Health Care Without Harm Europe

Chlumova 17

130 00 Prague, Czech Republic

tel./fax:

www.noharm.org

+420 222 782 808, 222 781 471

[email protected],

Non-Incineration

Medical Waste

Treatment Technologies

in Europe

June 2004

This resource book is based on the report ”Non-Incineration Medical Waste TreatmentTechnologies: A Resource for Hospital Administrators, Facility Managers, Health CareProfessionals, Environmental Advocates, and Community Members” issued by Health CareWithout Harm in August 2001. While the general chapters on waste minimisation and wastecategories are shortened, more space is given to the description of technologies that operate inEurope.

The final document was written by Dr. Jorge Emmanuel, HCWH, USA; Dr. Čestmír Hrdinka,HCWH, Czech Republic and Paweł Głuszyński, Waste Prevention Association, Poland withcontributions from Ralph Ryder, Communities Against Toxics, UK; Michael McKeon, IrishDoctors for the Environment, Ireland; Rui Berkemaier, Quercus, Portugal and Aurélie Gauthier,CNIID, France.

Health Care Without Harm EuropeChlumova 17

130 00 Prague 3, Czech RepublicTel.: +420 222 782 808Fax: +420 222 781 471

[email protected]

2 Health Care Without Harm

Preface

Until recently, incineration was the almostexclusive method of treating hazardous medicalwaste. In 1994, the U.S. Environmental ProtectionAgency’s (EPA) Reassessment of 2,3,7,8-Tetrachlorodibenzo-p-Dioxin (TCDD) andRelated Compounds identified medical wasteincineration as the single largest source of dioxinair pollution in the United States of America.In 1997, the EPA promulgated regulations forexisting and new incinerators, setting newemission limits. Existing incinerators had to beequipped with additional air pollution controldevices to comply with the new legislationrequirements. For the vast majority of hospitalsand other medical waste incinerator operatorshowever, investing in efficient filters was tooexpensive and resulted in the closure of morethan five thousands medical waste incinerators.

In 2000, stricter emission limits for medical wasteincinerators were introduced in the EuropeanUnion. This resulted in the closure of manyincinerators and an increase in the number of non-incineration facilities for treating infectious medicalwaste. However, the speed of the introduction ofalternative treatments is much slower than inthe USA and incineration remains the prevailingmethod of treating medical waste in Europe.

Although incineration is still widely used, non-incineration technologies are winning increasingsupport in Europe. In Slovenia, all infectiouswaste has been treated by using a steam-basedsystem since 90’s. Portugal has closed almost allits medical waste incinerators and is treatingmedical waste in autoclaves. More than 50operators in France have introducedshredding/steam/drying systems for medicalwaste treatment in last 10 years. The Joint WasteManagement Board of Ireland decided in 2003 todecontaminate the vast majority of its medicalwaste by autoclaves using hot steam.

Recently, 10 new countries entered the EuropeanUnion. Incineration facilities in these countriesare mostly old and not complying with EUemission limits for incinerators. In the CzechRepublic and Poland, (taking these countries as

examples), the overwhelming majority ofmedical waste incinerators exceed the dioxinemission limit of 0.1 ng/m3 TEQ.

There are two ways these new member countriescan meet the statutory limits in the future – theycan either equip incineration plants with veryexpensive filters, or close them and set up thealternative - non-incineration - technologies. Thelatter are more environmentally friendly andusually cheaper than incinerators. Non-incineration technologies (unlike incinerators) donot produce toxic dioxins and their introductionis therefore in accordance with the StockholmConvention on POPs (Persistent OrganicPollutants) that entered into force in May 2004.

It is widely accepted within the scientificcommunity that the incineration of waste resultsin the formation of Persistent Organic Pollutants,including dioxins, thus contributing to globalPOPs emissions. Although installation of new airemission control devices could reduce dioxinemissions in stack gas, this is usually accompaniedwith an increase of dioxin in fly ash. As theStockholm Convention recognises releases to air,water and land, future support for incinerationwould go against the primary goal of thisconvention, which is the reduction of POPs.

The problem of pollution caused by theincineration of medical waste has beenrecognised by the World Health Organisation(WHO). In its policy paper entitled “Health-careWaste Management” (March 2004) WHO statesthat a long-term goal shall be: “Effective, scaled-up promotion of non-incineration technologiesfor the final disposal of health-care wastes toprevent the disease burden from (a) unsafehealth-care waste management and (b) exposureto dioxins and furans.”

Health Care Without Harm hopes that allcountries in Europe will support the developmentof non-incineration medical waste treatmenttechnologies instead of choosing to reconstructand equip existing outdated incineration plants orsupporting the construction of new ones.

Non-Incineration Medical Waste Treatment Technologies in Europe 3

Executive summary

The international Convention on the Eliminationof Persistent Organic Pollutants (POPs) listsmedical waste incinerators among the maindioxin sources in the environment. However,medical waste incinerators emit a wide range ofpollutants besides dioxins and furans. Theseinclude heavy metals (lead, mercury andcadmium), fine dust particles, hydrogen chloride,sulphur dioxide, carbon monoxide, nitrogenoxides and other pollutants like Products ofIncomplete Combustion (PICs) into theatmosphere. They also generate highlycontaminated ash that is potentially hazardous tohuman health. It is scientifically acknowledgedthat these pollutants can have serious negativeimpacts on the health of incineration plantpersonnel, the public and the environment.

In order to maximise the benefits of non-incineration technologies, a basic concept ispresented of which the underlying elements arewaste minimisation and segregation.By implementing a program that includes sourcereduction, segregation, recycling and otherpollution prevention techniques, health-careservices can reduce the amount of infectiouswaste that needs to be decontaminated.

A waste analysis is an important step in selectingany non-incineration technology. Contrary topopular belief infectious medical waste is

estimated to be approximately 15% or less of

the overall waste stream. By the introduction ofefficient waste segregation and classificationsystems based on a real threat from infectiouswaste, this amount can be reduced in many casesto 3-5%.

Medical waste can be defined as waste generatedas a result of diagnosis, treatment andimmunisation of humans or animals. It is usefulto categorise the overall waste stream into thefollowing four categories: Municipal solid

waste, infectious waste, hazardous waste andlow-level radioactive waste. Waste categoriesare specified in the European Waste Catalogueand might be further defined by nationallegislation. Although infectious waste is only

a small part of the total waste generated bymedical facilities, it accounts for a considerableportion of the costs incurred by a health carefacility for the disposal of medical waste.

Four basic processes are used in alternativemedical waste treatment: thermal, chemical,irradiative and biological. Thermal processes relyon heat to destroy pathogens (disease-causingmicro-organisms). The low-heat processes utilisemoist heat (usually steam) or dry heat. Chemicalprocesses employ disinfectants to destroypathogens or chemicals to react with the waste.Irradiation involves ionising radiation to destroymicro-organisms while biological processes useenzymes to decompose organic matter.Mechanical processes, such as shredders, mixingarms, or compactors, are added as supplementaryprocesses to render the waste unrecognisable,improve heat or mass transfer, or reduce thevolume of treated waste.

For each of these processes, an overview andprinciples of operation are presented along withinformation on the types of waste treated,emissions, waste residues, microbial inactivationefficacy, advantages, disadvantages and otherissues. Specific examples of technologies inoperation in Europe are provided. Technologydescriptions are based on vendor data,independent evaluations and other non-proprietary sources where available. Sincetechnologies change quickly in a dynamicmarket, it is advisable for facilities interested inusing a non-incineration method to contact thevendors to get the latest and most accurate datawhen conducting the evaluation of anytechnology.

Health Care Without Harm does not endorse

any technology, company, or brand name, and

does not claim to present a comprehensive list

of technologies.


Steam disinfection, a standard process inhospitals, is done in autoclaves and retorts.Tuttnauer is an example of an autoclave. Morerecent designs have incorporated vacuuming,continuous feeding, shredding, mixing,fragmenting, drying, chemical treatment and/orcompaction, to modify the basic autoclavesystem. Examples of these so-called advancedautoclaves are: Ecodas, Hydroclave, Sterival, STI-CHEM Clav, STS, System Drauschke.

Microwave technology is essentially a steam-based low-heat thermal process wheredisinfection occurs through the action of moistheat and steam. Ecostéryl, Sanitec, Medister,Sintion, Sterifant, Steriflex are examples of largeand small microwave units, respectively. Dryheat processes do not use water or steam. Someheat the waste by forced convection, circulatingheated air around the waste or using radiantheaters.

Chemical technologies use disinfecting agents ina process that integrates internal shredding ormixing to ensure sufficient exposure to thechemical. Until recently, chlorine-basedtechnologies (sodium hypochlorite and chloridedioxide) were the most commonly used. Somecontroversy exists regarding possible long-termenvironmental effects, especially of hypochloriteand its by-products in wastewater. Non-chlorinetechnologies are quite varied in the way theyoperate and the chemical agents employed. Someuse peroxyacetic acid (Steris EcoCycle 10), ozonegas (Lynntech), lime-based dry powder, metalcatalysts (CerOx), or biodegradable proprietarydisinfectants. The alkaline hydrolysis technology(WR2) is designed for tissue and animal wastes aswell as fixatives, cytotoxic agents and otherspecific chemicals. Safety and occupationalexposures should be monitored when using anychemical technology.

Electron beam technology bombards medicalwaste with ionising radiation, causing damage tothe cells of micro-organisms. The University ofMiami’s Laboratories for Pollution ControlTechnologies is shown as an examples of e-beamtechnologies designed for medical wastetreatment. Unlike cobalt-60 irradiation, electronbeam technology does not have residualradiation after the beam is turned off.However, shields and safety interlocks are

necessary to prevent worker exposure to theionising radiation. Biological processes, such asthe Bio-Converter, use enzymes to decomposeorganic waste.

Health care facilities should consider thefollowing factors when selecting a non-incinerationtechnology:

• Regulatory acceptance

• Throughput capacity

• Types of waste treated

• Microbial inactivation efficacy

• Environmental emissions and waste residues

• Space requirements

• Utility and other installation requirements

• Waste reduction

• Occupational safety and health

• Noise

• Odour

• Automation

• Reliability

• Level of commercialisation

• Background of the technology manufactureror vendor

• Cost

• Community and staff acceptance.

No one technology offers a panacea to theproblem of medical waste disposal. Eachtechnology has its advantages and disadvantages.Facilities have to determine which non-incineration technology best meets their needswhile minimising the impact on theenvironment, enhancing occupational safetyand demonstrating a commitment to publichealth. This resource book provides generalinformation to assist legislators, hospitaladministrators, facility managers, health careprofessionals, environmental advocates andcommunity members towards achieving thosegoals.


Table of contents

Preface _____________________________________________________________________ 2

Executive summary __________________________________________________________ 3

Introduction: Why non-incineration technologies are preferable to incineration _____ 6

Incinerators emit toxic air pollutants _______________________________________________________ 6

Incineration ash is potentially hazardous ___________________________________________________ 6

Incinerators are expensive ________________________________________________________________ 6

Incinerators must meet new emission limits ________________________________________________ 7

International Convention on the Elimination of Persistent Organic Pollutants (POPs)_____________ 7

Waste reduction and segregation – the basic concept for the introduction

of non-incineration technologies_______________________________________________ 8

Medical waste categories ____________________________________________________ 10

Non-incineration technologies – general categories and processes _________________ 12

Low-heat thermal processes______________________________________________________________ 12

Chemical processes _____________________________________________________________________ 12

Irradiative processes ____________________________________________________________________ 12

Biological processes _____________________________________________________________________ 13

Mechanical processes ___________________________________________________________________ 13

Low-heat thermal technologies:

autoclaves, microwaves and other steam based systems _________________________ 15

Systems based on hot steam application – autoclaves, retorts _________________________________ 15

Microwave systems _____________________________________________________________________ 22

Low-heat thermal technologies – dry heat systems______________________________ 27

Chemical based technologies _________________________________________________ 29

Irradiation, biological and other technologies __________________________________ 33

Irradiation Technologies_________________________________________________________________ 33

Biological Systems ______________________________________________________________________ 34

Small Sharps Treatment Units ____________________________________________________________ 35

Factors to consider in selecting a non-incineration technology____________________ 36

Economics of treatment technologies __________________________________________ 38

Appendix: Non-incineration treatment technologies in Europe – case studies _______ 40

The Centre Hospitalier in Roubaix, France __________________________________________________ 40

Hospital waste management in Portugal ___________________________________________________ 40

Ireland has decided to treat hospital waste by a non-incineration technology ___________________ 41

Slovenia has treated infectious waste using hot steam mobile units since 1995 __________________ 41


Chapter 1

Introduction:

Why non-incineration technologies are preferable to incineration

INCINERATORS EMIT TOXIC AIR POLLUTANTS

Medical waste incinerators emit dioxins, furansand heavy metals including lead, mercury andcadmium, fine dust particles, hydrogen chloride,sulphur dioxide, carbon monoxide, nitrogenoxides, PICs (Products of Incomplete Combustion)and many other pollutants into the atmosphere.These compounds have serious negative impactson the health of incineration plant personnel, thepublic and the environment. The InternationalAgency for Research on Cancer (IARC) hasclassified the most toxic dioxin - 2,3,7,8 TCDD –as a group 1 human carcinogen while some otherdioxins are considered possible carcinogenicsubstances for human beings.1 Dioxins also affectthe hormonal system, impairs organism staminaand are associated with genetic defects, diabetes,endometriosis and a wide range of otherdiseases.2,3,4,5

Additional equipment or the installation ofvarious devices to reduce gaseous emissions willusually increase the content of these pollutants inthe solid waste phase. Moreover, the efficiency offilters in capturing very fine particles is limited;a proportion of 5% – 30% is quoted for very fineparticles smaller than 2.5 µm, being captured,while those under 1µm are hardly captured at all.These ultrafine particles are highly reactive, evenwhen coming from a relatively inert material.Recent research indicates that inhaling theseultrafine particles may have an adverse effect onhuman health.6

INCINERATION ASH

IS POTENTIALLY HAZARDOUS

As a rule, no additional equipment incorporatedinto an incineration plant with gaseous emissiontreatment devices will reduce the quantity ofdioxins emitted, but, as already stated, willsimply transform them into another waste phase.In an incinerator using the Best AvailableTechnology (BAT) the content of dioxins ingaseous emissions was only 2% of the total

dioxin content established in all incineratorwastes. The content of dioxins in ash, slag,settlings and filter cake was 6%, 72%, 2% and18% of the total quantity of released dioxinsrespectively7. In addition to dioxins and furansthe ash also contains other dangerous substancesand a high content of heavy metals (chrome,copper, lead, nickel, zinc) which can be releasedinto the environment.8

Fly ash containing heavy metals, dioxin, furansand other toxic substances fixes to the surface ofsmall particles that are carried by hot air and fluegases up through the incinerator chimney.The efficiency of capturing these substancesusing flue gas treatment devices depends on theefficiency and quality of the filters used.However, the best filters cannot capture allgaseous emissions. During the flue gas treatmentprocess harmful substances concentrate and aredeposited in filter cakes, activated charcoal andin the flue gas treatment process wastewater.This waste is usually classified as dangerous andhas to be treated accordingly.

Residual waste from both incineration plants andfrom non-incineration medical waste treatmenttechnologies9 has to be disposed of in landfills.In the hierarchy of waste treatment dumpingdecontaminated waste, which, with its properties,is similar to municipal waste, should be preferredto dumping dangerous waste resulting fromincineration. Moreover, the price for dumpinghazardous waste from incinerators at the speciallandfills required for this type of waste is severaltimes higher than that for dumpingdecontaminated medical waste at landfills formunicipal waste, thus increasing the costs tohealth-care facilities.

INCINERATORS ARE EXPENSIVE

The costs of building and operating an incineratoror a selected non-incineration technology maydiffer in various countries. This can be because of


different legislation – waste categorisation,different costs for hazardous and municipalwastes, the technology availability and otherfactors. Generally however, different non-incineration technologies are less expensive thanmedical waste incinerators. As an illustration,the costs of building an incineration plant in theUSA are 3 to 4 times higher than those ofprocessing the same quantity of waste in anautoclave10. Also the costs of operating non-incineration technology are usually lower thanthose of an incineration plant operation.

INCINERATORS

MUST MEET NEW EMISSION LIMITS

According to the European Union Directive No.2000/76/EC on waste incineration, medical wasteincinerators must meet the emission limit set at0.1 ng TEQ/m3 for dioxins and furans. Currently,the overwhelming majority of medical wasteincinerators in new member states and in somewest Europe countries, fail to meet this standard.To meet this limit in many cases incinerationplants have to be reconstructed or fitted withefficient filters. This can require an investment ofthousands, possibly millions of Euros. Investingin less expensive and environmental friendliernon-incineration technologies seems to be amuch more profitable alternative.

INTERNATIONAL CONVENTION

ON THE ELIMINATION OF PERSISTENT

ORGANIC POLLUTANTS (POPS)

The international Convention on the Eliminationof Persistent Organic Pollutants (POPs) wassigned in Stockholm, Sweden, in May 2001 andentered into force in May 2004. Article 5 requiresthat countries eliminate the generation of POPsincluding dioxins originating as by-products ofindustrial processes. Appendix C lists medicalwaste incinerators among the main sources ofdioxin in the environment.11

Most European countries are signatories of theStockholm Convention and therefore shouldprepare a plan for reducing persistent organicsubstances in the environment. Unlikeincineration plants, persistent organic pollutants(POPs) are not generated when treating medicalwaste using non-incineration technologies.

Therefore the introduction of non-incinerationtechnologies for the treatment of medical waste isa suitable way of meeting the obligations arisingfrom the Stockholm Convention.

1 McGregor, DB., Partensky, C., Wilbourn, J., Rice, JM.:An IARC evaluation of polychlorinated dibenzo-p-dioxins and polychlorinated dibenzofurans as riskfactors in human carcinogenesis. Environ. HealthPerspect., 1998,106(2):755-60.

2 Egeland, G., Sweeney, M., Fingerhut, M., Wille, K.,Schnoor, T. Total serum testosterone andgonadotropins in workers exposed to dioxin. Am. J.Epidemiol., 1994, 139:272-281.

3 Birnbaum, L. Developmental Effects of Dioxins.Environ. Health Perspect., 1995, 103(Suppl 7):89-94.

4 Weisglas-Kuperus, N. Neurodevelopmental, immuno-logical and endocrinological indices of perinatalhuman exposure to PCBs and dioxins. Chemosphere,1998, 37:1845-1853.

5 Sweeney, M., Hornung, R., Wall, D., Fingerhut, M.,Halperin, W. Prevalence of diabetes and elevatedserum glucose levels in workers exposed to 2,3,7,8-tetrachlordibenzo-p-dioxin (TCDD). Presented at the12th International symposium on Dioxins and Relatedcompounds, Tampere, Finland, 24-28 August 1992.

6 Howard C.V., 2000. Particulate Aerosols, Incineratorsand Health, in P. Nicolopoulou-Stamati et.al. (eds.),Health Impacts of Waste Management Policies, 155-174, Kluwer Academic Publishers, 2000.

7 Giugliano, M., Cernuschi, S., Grosso, M., Miglio, R.,and Aloigi, E. PCDD/F mass balance in the flue gascleaning units of a MSW incinerator plant.Chemosphere, 2002, 46:1321-1328.

8 Čížek Zdeněk. The problematics of the laboratoryevaluation of the medical waste qualities. Waste fromhealth care, proceedings, BIJO, 2000.

9 Decontaminated waste from many hospitals inEurope, i.e. in Austria and in Czech Republic,is subsequently incinerated, whereby the real purposeof implementing non-incineration technologies is toeliminate dangerous persistent organic substancesgenerated by waste incineration.

10 Emmanuel. J, Non-incineration Alternatives to theTreatment of Medical Waste. Presented at theconference “Environmentally friendly management ofmedical waste”, Debeli rtič, Slovenia, 12th April 2002.

11 http://www.pops.int


Chapter 2

Waste reduction and segregation

– the basic concept for the introduction of non-incineration technologies

Before dealing with the technical and economicissues relating to non-incineration technologies(Chapters 3 to 10), it is crucial to consider the useof these technologies in a broader context.An alternative technology must encompass astrategic framework dealing with various aspectsof medical waste management and in doing soensure that the maximum environmental,occupational safety and economic benefits ofnon-incineration technologies can be achieved.

In the past, many hospitals simply dumped alltheir waste streams together — waste from thereception area, kitchen waste, operating roomwastes, contaminated sharps and lab waste etc. —and burned them in their incinerators. There wereno incentives to separate, recycle, or reduce waste.A commitment to public health andenvironmental protection, regulatory complianceand the need to reduce costs requires a newframework for dealing with hospital waste.

The underlying elements of a strategicframework are waste minimisation andsegregation. Different components of the wastestream must be kept separate from each other.Specifically, potentially infectious waste,municipal waste, hazardous waste and low-levelradioactive waste must be segregated. Everyeffort must be made to minimise each of thesewaste streams and each must be disposed ofproperly. The infectious waste that remains canthen be treated using a non-incinerationtechnology. (Note: Some facilities incinerate waste

that had already been treated by a non-incineration

technology thereby defeating the purpose of using an

alternative.)

Waste minimisation is the reduction, to thegreatest extent possible, of waste that is destinedfor ultimate disposal by means of reuse, recyclingand other programs. The potential benefits ofwaste minimisation are: environmentalprotection, enhanced occupational safety andhealth, cost reductions, reduced liability,

regulatory compliance, and improvedcommunity relations. The following is therecommended hierarchy of waste minimisationtechniques in order of decreasing preference:

1. Source reduction - minimising or eliminatingthe generation of waste at the source itself.Source reduction should have a higherpriority than recycling or reuse. Medicalstaff, waste managers, and productstandardisation committees should be awareof what proportions of the waste stream aregenerated by the products they buy. Indeed,the close involvement of purchasing staff iscritical to the effectiveness of any sourcereduction scheme. Steps should be taken toreduce at source regulated medical waste,hazardous waste, low-level radioactivewaste, as well as regular trash. Some specificsource reduction techniques include:

a. Material elimination, change or product

substitution, e.g., substituting a non-toxicbiodegradable cleaner for one that generateshazardous waste; employing multiple-useitems instead of single-use products; usingshort-lived radionuclides instead of radium-226 needles in cancer treatment;

b. Technology or process change, e.g.,using non-mercury-containing devicesinstead of mercury thermometers ormercury switches; using ultrasonic orsteam cleaning instead of chemical-basedcleaners, replacing chemical basedprocess for development of radiographywith a computer one;

c. Preferential purchasing such as selectingvendors with reduced packaging,product recyclability;

d. Good operating practice, e.g., improvinginventory control; covering disinfectingsolution trays to prevent evaporativelosses; using the minimum formulationrecommended for an application.


2. Segregation – making sure waste items areput in the appropriate containers. Stafftraining is essential to keep infectiousmedical wastes and hazardous waste such asmercury, low-level radioactive waste, andmunicipal waste separated from each other.

3. Resource recovery and recycling - recoveryand reuse of materials from the waste stream.Some specific examples include:

a. Recycling newspapers, packagingmaterial, office paper, glass, aluminiumcans, construction debris, and otherrecyclable;

b. Purchasing products made of post-consumer recycled material;

c. Composting organic food waste;

d. Recovering silver from photographicchemicals.

4. Treatment - treatment to remove andconcentrate waste, preferably duringprocesses rather than end-of-pipe treatment.An example might be the use of filters andtraps to remove mercury from wastewater.In the case of infectious waste, the treatmententails the destruction of pathogens. This iswhere non-incineration technologies come in.

5. Proper Disposal – when all possible wasteminimisation options have been exhausted,the remaining waste should be disposed inthe method with the least environmentalimpact. With most non-incinerationtechnologies, the treated waste can bedisposed in a regular municipal wastelandfill.

Health Care Without Harm does not support

the incineration, gasification, pyrolysis or

plasma destruction of medical waste as means

of decontamination or treatment after

disinfection.


Chapter 3

Medical waste categories

A waste analysis is an important step in selectingthe non-incineration technology that best meetsthe needs of the facility. Furthermore, a wastestream analysis is a basis for identifying wasteminimisation options and establishing the degreeof segregation. Through an analysis, the healthcare facility can establish whether or not somewaste is being “over-classified” as bio-hazardouswaste, and assess compliance with existingregulations on waste handling and disposal.A waste audit is a powerful tool for analysing thehospital waste stream.

Medical waste can be defined as waste generatedas a result of diagnosis, treatment, andimmunisation of humans or animals. It is usefulto categorise the overall waste stream into thefollowing four categories:

1. Municipal solid waste includes recyclable orcompostable materials.

2. Infectious waste is generally defined aswaste that is capable of producing infectiousdisease. Other terms used include bio-hazardous waste, biomedical waste, or “redbag” waste. Infectious waste must be treatedand decontaminated before landfilling(Directive 99/31/EC).

3. Hazardous waste is defined as waste that maycause or significantly contribute to mortalityor serious illness or pose a substantial hazardto human health and the environment ifimproperly managed or disposed of.

4. Low-level radioactive waste is waste thatexhibits radiologic characteristics such asradioactive decay.

Table 3-1. A comparison of medical waste categories according to EU Waste Catalogue and WHO.

European Waste Catalogue Categories of health-care waste (WHO)

18 01 01 sharps (except 18 01 03) Sharps

18 01 02 body parts and organs including blood

bags and blood preserves (except 18 01 03)Pathological waste

18 01 03* wastes whose collection and disposal is

subject to special requirements in order to prevent

infection

Infectious waste

18 01 04 wastes whose collection and disposal is not

subject to special requirements in order to prevent

infection (for example dressings, plaster casts,

linen, disposable clothing, diapers)

Non-risk or “general” health-care waste

18 01 06* chemicals consisting of or containing

dangerous substances

Chemical waste

Waste with high content of heavy metals

18 01 07 chemicals other than those mentioned in

18 01 06Chemical waste

18 01 08* cytotoxic and cytostatic medicines Genotoxic waste

18 01 09 medicines other than those mentioned in

18 01 08Pharmaceutical waste

18 01 10* amalgam waste from dental care Waste with high content of heavy metals

15 01 11* metallic packaging containing a dangerous

solid porous matrix (for example asbestos),

including empty pressure containers

Pressurised containers

National regulation [EU proposal: COM(2003) 32 final] Radiological waste

(*) Indicates waste classified as hazardous


Waste categories are specified in the EuropeanWaste Catalogue, and might be further definedby national legislation. The main focus of thisresource guide is the treatment of regulatedmedical waste.

Infectious waste is estimated to be 15% or less

of the overall waste stream. By introduction ofefficient waste segregation and classificationsystems based on a real threat from infectiouswaste, the amount might be reduced to 3 - 5%.1

Although infectious waste is only a small part ofthe total waste generated by medical facilities, itmakes up a considerable part of the costs ofmedical waste disposal. While the proportion ofinfectious waste in the Hospital Na Homolce(Czech Republic) in 2001 was only 17% of thetotal hospital waste, the costs of its disposal was81% of the total costs of disposing of all waste.2

1 Institute of Environmental Medicine and HospitalEpidemiology. Reduction and utilisation of hospitalwaste, with the focus on Toxic and infectious waste.Final report, LIFE96/ENV/D/10, Freiburg, August 2000.

2 Based on information provided by the hospitalNa Homolce, Czech Republic.


Chapter 4

Non-incineration technologies – general categories and processes

Non-incineration treatment technologies can beclassified in many ways - such as according tosize, purchase price, types of waste handled, ormarket share. In this chapter, the technologieswill be categorised based on the fundamentalprocesses used to decontaminate waste. The fourbasic processes are:

1. Low-heat thermal processes

2. Chemical processes

3. Irradiative processes

4. Biological processes

The majority of non-incineration technologiesemploy the first two processes listed above.Presented below are each of these processes aswell as mechanical processes which supplementthe four fundamental processes.

Thermal processes are those that rely on heat(thermal energy) to destroy pathogens in thewaste. This category is further subdivided intolow-heat, medium-heat, and high-heat thermalprocesses. This further sub-classification isnecessary because physical and chemicalmechanisms that take place in thermal processeschange markedly at medium and hightemperatures.

Low-heat thermal processes are those that usethermal energy to decontaminate the waste attemperatures insufficient to cause chemicalbreakdown or to support pyrolysis orcombustion. Medical waste incinerators,pyrolysis, gasification, and plasma arctechnologies are considered to be high-heatprocesses, involving chemical and physicalchanges to both organic and inorganic materialresulting in destruction of the waste.

Medical waste incinerators are a major source ofpersistent organic pollutants, including dioxins.Due to the negative impact on human health,incineration of medical waste should not berecommended and the preferred treatment formedical waste.

LOW-HEAT THERMAL PROCESSES

In general, low-heat thermal technologies operatebetween 93°C to about 177°C. Two basiccategories of low-heat thermal processes are wetheat (steam) and dry heat (hot air) disinfection.Wet heat treatment involves the use of steam todisinfect and sterilise waste and is commonlydone in an autoclave. Microwave treatment isessentially a steam disinfection process sincewater is added to the waste and destruction ofmicro-organisms occurs through the action ofmoist heat and steam generated by microwaveenergy1. In dry heat processes, no water or steamis added. Instead, the waste is heated byconduction, natural or forced convection, and/orthermal radiation using infrared heaters.

CHEMICAL PROCESSES

Chemical processes employ disinfectants suchas dissolved chlorine dioxide, bleach (sodiumhypochlorite), peracetic acid, or dry inorganicchemicals. To enhance exposure of the waste tothe chemical agent, chemical processes ofteninvolve shredding, grinding, or mixing. Inliquid systems, the waste may go through adewatering section to remove and recycle thedisinfectant. Besides chemical disinfectants,there are also encapsulating compounds thatcan solidify sharps, blood, or other body fluidswithin a solid matrix prior to disposal. Onedeveloping technology uses ozone to treatmedical waste and others utilise catalyticoxidation. A novel system uses alkali tohydrolyse tissues in heated stainless steel tanks.

IRRADIATIVE PROCESSES

Irradiation-based technologies involve electronbeams, Cobalt-60, or UV irradiation. Thesetechnologies require shielding to preventoccupational exposures. Electron beamirradiation uses a shower of high-energyelectrons to destroy micro-organisms in thewaste by causing chemical dissociation andrupture of cell walls. The pathogen destructionefficacy depends on the dose absorbed by the


mass of waste, which in turn is related to wastedensity and electron energy. Germicidalultraviolet radiation (UV-C) has been used as asupplement to other treatment technologies.Irradiation does not alter the waste physicallyand would require a grinder or shredder torender the waste unrecognisable.

BIOLOGICAL PROCESSES

Biological processes employ enzymes to destroyorganic matter. Only a few non-incinerationtechnologies have been based on biologicalprocesses.

MECHANICAL PROCESSES

Mechanical processes - such as shredding, grinding,hammermill processing, mixing, agitation, liquid-solid separation, conveying (using augers2, rams, orconveyor belts), and compaction – supplementother treatment processes. Mechanical destructioncan render the waste unrecognisable and is used todestroy needles and syringes so as to minimiseinjuries or to render them unusable. In the case ofthermal- or chemical-based processes, mechanicaldevices such as shredders and mixers can alsoimprove the rate of heat transfer or expose moresurfaces to chemical disinfectants. Mechanicalprocesses can add significantly to the level ofmaintenance required.

A mechanical process is supplementary andcannot be considered a treatment process per se.

Unless shredders, hammermills, and other mechanical

destruction processes are an integral part of a closed

treatment system, they should not be used before the

waste is decontaminated. Otherwise, workerswould be exposed to pathogens released to theenvironment by mechanical destruction.If mechanical processes are part of a system, thetechnology should be designed in such a waythat the air in and from the mechanical process isdisinfected before being released to thesurroundings. It is especially important for air tobe drawn into the mechanical process (awayfrom the inlet) when waste is being fed. This isoften done using a draft fan that maintains anegative pressure in the mechanical processingchamber; air taken from the mechanical processpasses through the disinfection chamber orthrough a high efficiency particulate air (HEPA)filter before being released to the environment.

Table 4-1 lists some non-incinerationtechnologies according to category. Thesetechnologies range from small units for use at ornear the point of generation to high-capacitysystems for large medical centres or regionalfacilities.

These technologies are described in subsequentchapters.

1 Various studies show that the lethal effect ofmicrowaves on microbial organisms is primarily dueto moist heat; without water or steam, microwaveenergy alone results in no significant cell inactivation.See, for example, G.R. Vela and J.F. Wu. Applied andEnvironmental Microbiology, 1979, 37(3), 552.

2 An auger is essentially a large screw that rotatesinside a cylinder thereby moving the waste forward.

Table 4-1. Non-incineration treatment technologies for medical waste

Non-incineration Technology Technology name, vendor

LOW-HEAT THERMAL PROCESSES

Autoclave or Retort Tuttnauer

Shredding-Steam-Mixing/Drying Ecodas

Steam-Mixing-Fragmenting/Drying Hydroclave Systems Corp.

Shredding-Steam-Mixing/Drying, Chemical Steriflash, T.E.M.

Vacuum-Steam/Drying/Shredding Sterival, Starifant Vetriebs GmbH

Shredding-Steam/Drying, Chemical STI Chem-Clav, Waste Reduction Europe Ltd

Shredding-Steam-Mixing/Compaction STS, Erdwich Zerkleinerungssysteme GmbH


Non-incineration technology Technology name, vendor

Vacuum-Steam/Drying/Shredding System Drauschke, GÖK Consulting AG

Vacuum/Vacuum-Steam/Drying WEBECO GmbH & Co. KG

Steam-Fragmenting/Drying ZDA-M3, Maschinenvertrieb für Umwelttechnik GmbH

Microwave Treatment Ecostéryl, AMB S.A.

Microwave Treatment Medister, Meteka

Microwave Treatment Sanitec

Microwave Treatment Sintion, CMB Maschinenbau und Handels GmbH

Vacuum-Steam/MicrowaveTreatment/Drying/Shredding

Sterifant Vertriebs GmbH

CHEMICAL PROCESSES

Fragmenting-Steam-NaClO/Cl2O Newster, Multiservice First s.r.l.

Alkaline Hydrolysis WR2, Waste Reduction Europe Ltd

IRRADIATION PROCESSES

Electron Beam-Shredding U. Miami E-Beam

BIOLOGICAL PROCESSES

- Today not available in Europe

Health Care Without Harm does not endorse any technology, company, or brand name.

These technologies are listed here as examples of alternatives to traditional incineration.

HCWH does not claim that this is a comprehensive listing.


Chapter 5

Low-heat thermal technologies:

autoclaves, microwaves and other steam based systems

SYSTEMS BASED ON HOT STEAM

APPLICATION – AUTOCLAVES, RETORTS

Steam disinfection, a standard process inhospitals for sterilising reusable instruments, hasbeen adapted for medical waste treatment. Thereare two traditional types of equipment used forsteam treatment: autoclaves and retorts. Othersteam-based systems, sometimes referred to asadvanced autoclaves, have been developed inrecent years. One unique design of a steam-basedprocess is a microwave unit that achievesdisinfection or sterilisation by means of moistheat and steam.

An autoclave consists of a metal chamber sealedby a charging door and surrounded by a steamjacket. Steam is introduced into both the outsidejacket and the inside chamber which is designedto withstand elevated pressures. Heating theoutside jacket reduces condensation in the insidechamber wall and allows the use of steam atlower temperatures. Because air is an effectiveinsulator, the removal of air from the chamber isessential to ensure penetration of heat into thewaste. This is done in two general ways: gravitydisplacement or pre-vacuuming.

A gravity-displacement (or downward-displacement)

autoclave takes advantage of the fact that steam islighter than air; steam is introduced underpressure into the chamber forcing the airdownward into an outlet port or drain line in thelower part of the chamber. A more effectivemethod is the use of a vacuum pump to evacuateair before introducing steam, as is done in pre-vacuum autoclaves.

Pre-vacuum (or high-vacuum) autoclaves need lesstime for disinfection due to their greaterefficiency in taking out air. Some autoclaves mayuse pressure pulsing with or without gravitydisplacement to evacuate air.

A retort is similar to an autoclave except that ithas no steam jacket. It is cheaper to construct but

requires a higher steam temperature than anautoclave. Retort-type designs are found in large-scale applications.

HOW IT WORKS

A typical operating cycle for an autoclave orretort involves the following:

• Waste collection: A cart or bin is lined withspecial plastic liners or large autoclavablebags to prevent waste from sticking to thecontainer. Red bags are then placed in thelined container.

• Pre-heating (for autoclaves): Steam is introducedinto the outside jacket of the autoclave.

• Waste loading: Waste containers are loadedinto the autoclave or retort chamber.Periodically, chemical or biologicalindicators are placed in the middle of thewaste load to monitor disinfection. Thecharging door is closed, sealing the chamber.

• Air evacuation: Air is removed throughgravity displacement or pre-vacuuming asexplained above.

• Steam treatment: Steam is introduced into thechamber until the required temperature isreached. Additional steam is automaticallyfed into the chamber to maintain thetemperature for a set time period.

• Steam discharge: Steam is vented from thechamber, usually through a condenser, toreduce the pressure and temperature. Insome systems, a post-vacuum cycle is usedto remove residual steam.

• Unloading: Usually, additional time isprovided to allow the waste to cool downfurther, after which the treated waste isremoved and the indicator strips, if any, areremoved and evaluated.

• Mechanical treatment: Generally, the treatedwaste is fed into a shredder or compactorprior to disposal in a sanitary landfill.


TYPES OF WASTE TREATED

The types of waste commonly treated inautoclaves and retorts are: cultures and stocks,sharps, materials contaminated with blood andlimited amounts of fluids, isolation and surgerywastes, laboratory wastes (excluding chemicalwaste), and soft wastes (gauze, bandages, drapes,gowns, bedding, etc.) from patient care. Withsufficient time and temperature as well asmechanical systems to make the wasteunrecognisable it is technically possible to treathuman anatomical wastes but ethical, legal, cultural,and other considerations preclude their treatment.

Volatile and semi-volatile organic compounds,chemotherapeutic wastes, mercury, otherhazardous chemical wastes, and radiologicalwastes should not be treated in an autoclave orretort. Huge and bulky bedding material, largeanimal carcasses, sealed heat-resistant containers,and other waste loads that impede the transfer ofheat should also be avoided.

EMISSIONS AND WASTE RESIDUES

Odours can be a problem around autoclaves andretorts if there is insufficient ventilation.

If waste streams are not properly segregated toprevent hazardous chemicals from being fed intothe treatment chamber, toxic contaminants willbe released into the air, condensate, or in thetreated waste. This is the case when waste loadscontaminated with antineoplastic drugs or heavymetals such as mercury are put in the autoclave.Thus, poorly segregated waste may emit lowlevels of alcohol, phenols, aldehydes, and otherorganic compounds in the air. More independentemission tests of autoclaves operating undertypical conditions would be useful.

A study1 at one autoclave facility by the USNational Institute for Occupational Safety andHealth (NIOSH) found no volatile organiccompounds (VOCs) in a worker’s personal airspace and work area that exceeded permissibleexposure limits set by the US Occupational Safetyand Health Administration. The highest VOClevel in the autoclave facility was 2-propanol,measured at 643 mg/m3. Some autoclaves orretorts may use steam that is treated withcorrosion inhibitors or anti-scaling agents (smallamounts of neutralising amines).

There have been dubious claims that dioxin maybe created in autoclaves and at levels even higherthan those from incinerators. The authors are notaware of any scientific paper showing this.Researchers generally agree that dioxins areformed at temperatures between 250 to 450°C,temperatures well above the operatingtemperatures of autoclaves. Moreover, dioxinformation is believed to be catalysed by fly ashcreated during combustion in the presence ofmetals and a chlorine source. Both the abovementioned temperature range and fly ash are notfound in autoclaves since burning does not takeplace in an autoclave. However, these conditions,along with known precursors (compoundsproduced by burning that lead to the formationof dioxin) are found in the exhaust downstreamfrom the combustion chambers of incinerators.

Decontaminated waste from an autoclave orretort retains its physical appearance. Somelandfill operators may refuse to accept treatedwaste that is recognisable. Since steam does notphysically alter the waste in any significant way,a mechanical process such as a shredder orgrinder is needed to render the wasteunrecognisable. Shredding reduces the volume ofthe treated waste by 60 to 80 percent.

MICROBIAL INACTIVATION

Autoclaves and retorts require a minimumexposure time and temperature to achieve properdisinfection or sterilisation. Time-temperaturerecommendations for various conditions arefound in a number of references2. Often, theexposure times are based on twice the minimumtime required to achieve a 6 log10 kill of bacterialspores under ideal conditions; equivalentexposure times at different temperatures can beestimated. A common exposure temperature-time criterion is 121°C for 30 minutes.

Colour-changing chemical indicators orbiological monitors (e.g., B. stearothermophilus orB. subtilis spore strips) placed at the centre of testloads should be used to verify that sufficientsteam penetration and exposure time haveoccurred.


ADVANTAGES AND DISADVANTAGES

OF THE TECHNOLOGY

Autoclaves and retorts have the followingadvantages:

• Steam treatment is a proven technology witha long and successful track record.

• The technology is easily understood andreadily accepted by hospital staff andcommunities.

• It is approved or accepted as a medical wastetreatment technology in most countries.

• The time-temperature parameters needed toachieve high levels of disinfection are wellestablished.

• Autoclaves are available in a wide range ofsizes, capable of treating from a fewkilograms to several tons per hour.

• If proper precautions are taken to excludehazardous materials, the emissions fromautoclaves and retorts are minimal.

• Capital costs are relatively low .

• Many autoclave manufacturers offer featuresand options such as programmable computercontrol, tracks and lifts for carts, permanentrecording of treatment parameters, autoclavablecarts and cart washers, and shredders.

The disadvantages include the following:

• The technology does not render wasteunrecognisable and does not reduce thevolume of treated waste unless a shredder orgrinder is added.

• Any large, hard metal object in the waste candamage any shredder or grinder.

• Offensive odours can be generated but areminimised by proper air handling equipment.

• If hazardous chemicals such asformaldehyde, phenol, cytotoxic agents, ormercury are in the waste, these toxiccontaminants are released into the air,wastewater, or remain in the waste tocontaminate the landfill.

• If the technology does not include a way ofdrying the waste, the resulting treated wastewill be heavier that when it was first put inbecause of condensed steam.

• Barriers to direct steam exposure or heattransfer (such as inefficient air evacuation;excessive waste mass; bulky waste materialswith low thermal conductivity; or waste loadswith multiple bags, air pockets, sealed heat-resistant containers, etc.) may compromise theeffectiveness of the system to decontaminatewaste. Examples of waste that may need to becollected separately and treated using anothertechnology include evacuated containers andpleurovac machines.

EXAMPLES OF SYSTEMS BASED ON

STEAM APPLICATION

Some examples of hot steam based systems are inTable 4-1. The following are descriptions of allvendors known to the authors as of the time ofthis publication. While there may be othermanufacturers in the market, there was noattempt to make this a comprehensive list. Asnoted earlier, mention of a specific technology inthis report should not be construed as anendorsement by Health Care Without Harm

Tuttnauer

Red bags are placed in an autoclavable bag andmanually placed into autoclave baskets restingon a carriage. The full basket is rolled off thecarriage into the autoclave chamber.The operator closes the door and pushes a buttonto automatically start a pre-programmed cycle.Air is removed using a vacuum and heated to148°C in a heat exchanger prior to discharge inthe sewer. Steam is introduced and the waste isexposed for a set period. The vessel can operateup to 155°C and 2.27 bar. After treatment, a highvacuum is pulled to cool and dry the waste.The basket is then rolled out of the chamber andonto the carriage, where it can be transported toa shredder or compactor. The units are equippedwith microcomputer-based controls.

Capacity: Up to 680 kg/h.

Capital Costs: 85 – 170 000 EUR.

Technical information: Temperature: 148 - 155°C;pressure: 2.27 bar; time of exposure: 20 minutes.

Stage of commercialisation: Commercialised.


Vendor’s contact: Tuttnauer Co. Ltd., 25 PowerDrive Hauppauge, NY,11788, USA, tel.: +1 631737 4850, e-mail: [email protected],www.tuttnauer.com; Tuttnauer Europe b.v.,Paardeweide 36, P.O.B. 7191, 4800 GD Breda,The Netherlands, tel: +31 765 423 510, e-mail:[email protected]

Ecodas

Medical waste is loaded from the top of themachine into a chamber equipped at the bottomwith heavy-duty shredder. If waste containssome large unbreakable objects, like metal parts,the shredder stops automatically, and thechamber is not opened until waste is sterilised bysteam. Shredded waste falls by gravity into thelower chamber. The machine is steam heated to atemperature of 138°C and pressure is increasedto 3.8 bar.

The fully automatic and online controlled processhas a cycle time of 40 - 60 minutes, dependingupon the size of plant and the amount of waste.Sterile fragments (8 log10 reduction) are dischargedfrom the bottom of the machine and disposed ofin a conventional landfill site. The originalvolume of waste is reduced by 80%.

There are three different models of Ecodas.The major difference between T1000 and T300 isthe height and between T2000 and T1000the diameter. Therefore T2000 and T1000 requirea hoist loading system. The cost of wastetreatment process ranges from 0.05 to 0.09EUR/kg. Approximate investment costs are from145 000 to 400 000 EUR3.

Ecodas autoclaves are installed in several placesin France, mostly in individual medical facilities,but are operated also as central units for otherhospitals, for example in Santes or Loos. Thesesystems are also operated in Cyprus, Hungary,Poland, Russia, Spain, and some non-Europeancountries such as Argentina, Brazil, Mexico,Japan, Egypt, Lebanon, Guyana and Morocco.

Capacity: 25 (0.3 m3)/80 (1 m3)/190 kg/h (2 m3).

Capital costs: from 145 000 EUR.

Technical information: Temperature: 138°C;pressure: 3.8 bar; exposure time: 10 minutes.

Stage of commercialisation: Commercialised,since 1993.

Vendor’s contact: Ecodas, 28, rue Sebastopol,59100 Roubaix, France; tel.: +33 3 20 70 98 65, fax:+33 3 20 36 28 05, e-mail: [email protected],www.ecodas.com

Hydroclave

The Hydroclave is basically a double-walled(jacketed) cylindrical vessel with mixing andfragmenting paddles inside. The waste is loadedthrough the loading door on top of the vessel.After the door is closed, high temperature steamenters the outside jacket to heat up the waste viathe hot inner surface. During this time, a shaftand paddles rotate inside to fragment and tumblethe waste. The moisture in the waste turns tosteam and pressurises the inner vessel; however,if there is not enough moisture, a small amountof steam is added until the desired pressure ismet. The temperature is maintained at 132°C for15 minutes (or 121°C for 30 minutes) while themixing paddles continue to rotate. Aftertreatment, the steam is vented through acondenser while maintaining heat input, causingthe waste to dry. The steam to the jacket is shutoff, the discharge door is opened, and the shaftand paddles reverse rotation to scoop the wasteout through the loading door onto a conveyor orwaste container. A strip chart recorderdocuments the process parameters.

Capacity: 90 - 900 kg/h.

Capital costs: 170 000 - 420 000 EUR.

Technical information: Temperature: 132°C; timeof exposure: 15 minutes.


Vendor’s contact: Hydroclave SystemCorporation, 672 Norris Court, Kingston, ON.Canada K7P 2R9, tel.: +1 613 389-8373, fax:+1 613 389-8554, e-mail: [email protected],www.hydroclave.com


Steriflash

Steriflash is an autoclave intended for a smallwaste quantity. It can be installed near the placeof waste origin.

Waste deposited in the hopper is mechanicallyshredded and then falls into the treatment tank.The process begins by the injection of saturatingwet steam supplied by an external steamgenerator (outside the process chamber).The temperature achieved is 134°C at 2.3 barpressure for 20 minutes.

At the end of the cycle, the front door opensautomatically and the solid spun waste isreleased into a container - liquids are drained offvia the waste water system.

Gaseous discharges are filtered (0.3µ filter),condensed and treated by bubbling.

Steriflash installations operate in France, Greece,and Spain. Company is also present on German,Norwegian, Polish, and Swedish market.

Capacity: Approx. 16 kg/cycle (0.38 m3).

Capital costs: 30 000 EUR.

Technical information: Temperature: 134°C;pressure: 2.3 bar; time of exposure: 20 minutes.


Vendor’s contact: T.E.M.; Hôtel d'entreprisesZI la Pradelle voie la pradelle, 31190 Auterive,France; tel.: + 33 5 342 80 234, fax: + 33 5 342 80237, e-mail: [email protected], www.steriflash.fr

Sterival

The Sterival system is designed for on-sitesterilisation of infectious waste. The system ismodular and its configuration can be adapted atany time to the capacity required.

The Sterival system consists of an energy (base)and steam supply module. The base module maycontrol up to 4 sterilisation modules and byadding extensions units of 2 up to 4 modules canbe assembled. The system uses 60 litres reusableSterifant PC-waste bins. These can be used inaverage 200-300 times, depending on the binmodel.

The duration of the complete sterilisation cycle at136°C ranges from 25 to 35 minutes, dependingon the waste content, and assuming 12 kg ofwaste per bin.

The systems require no chemicals, as wastes aresterilised solely by a pulsed vacuum and saturatedsteam.

Combining the modules with the Sterifant stand-alone shredder can reduce the volume of thepost-process waste up to 80%.

The waste treatment process is specified in the listof approved disinfecting processes under § 10 c ofthe German Epidemics Control Act compiled bythe Federal German Health Agency under thename of Valides System. Sterival modularsterilisation system of medical waste is installed(as the Valides System) in the new constructedLondon Hospital in Kuwait, moreover in themajor hospital in Munich, Germany.

Capacity: Approx. 21 – 84 kg/h.

Capital costs: 98 100 – 200 400 EUR.



Vendor’s contact: Sterifant Vertriebs GmbH; 12,Rue Jean Engling, L-1466 Luxembourg; tel.: +352-43 22 22-1, fax: +352-42 60 59, [email protected],www.sterifant.com

STI Chem-Clav

With the STI Chem-Clav, the waste is loaded viafeed conveyors or cart dumpers into the hopperwhere a negative pressure is maintained bydrawing air through a high efficiency particulateair filter (HEPA). The waste in the hopper dropsinto a heavy-duty shredding unit wheredownward pressure is applied using a ram.An integral process controller controls the feedmechanism. Shredded material enters a rotatingauger conveyor where low-pressure steam isintroduced through multiple ports maintainingthe temperature in the conveyor between 114 to128°C. Downstream of the conveyor is adehydration section wherein a steam jacketincreases temperatures above 118°C. The steam isdischarged through a vent at the very end of


the conveyor and through a condenser causingthe waste to dry off. The decontaminated wasteexits the conveyor into a self-containedcompactor or roll-off container for transport toa landfill. A chemical subsystem injects sodiumhypochlorite mist for cleaning and odour control.The heavy-duty shredder reduces waste volumeup to 90%.

Capacity: 270 – 1800 kg/h.

Capital costs: From 305 000 EUR.

Technical information: Temperature: 118 - 128°C.

Stage of commercialisation: Commercialisedsince 1995.

Vendor’s contact: Waste Reduction by WasteReduction Europe Ltd., Clydebank RiversideMedi-Park, Beardmore Street, Clydebank,Glasgow G81 4SA, UK; tel.: +44 0 141 951 5980,fax: +44 0 141 951 5985; e-mail:[email protected], www.wreurope.net;www.stichemclav.com

STS

Medical waste is fed into a funnel througha hydraulic lift mechanism, and shredded afterthe funnel lid is closed. The shredded “cold”waste is enriched with certain basic moisturecontent by adding vapour in the lower part of thescrew. During the transport process, the waterevaporates due to contact with the heated screwwalls and evaporation heat is transferred to the“cold” material during the subsequentcondensation process. Due to condensation andconvection the temperature of the waste issteadily increased.

The heated waste is then transported to thethermal screw, which is also equipped with athermal oil jacket heating system. During thisstage, the temperature range is between 124 –134°C, and 140°C, but in special cases it can beincreased up to 150°C. The material is keptcontinually in motion during sterilisation process.

As a result of the motion and the loose bulkdensity of the waste in the thermal screw, thewaste is compressed on its way to the discharger.Disinfected and sterilised waste is pourable andits volume reduced considerably.

This technology can be used not just forprocessing of hospital specific waste, but also forcatering waste, slaughterhouse waste, liquids,animal testing laboratories etc.



Technical information: Temperature: 124 - 150°C;pressure: 2.4 bar; exposure time: 20 minutes.


Vendor’s contact: Erdwich ZerkleinerungssystemeGmbH, Kolpingstrasse 8, D-86916 Kaufering,Germany; tel.: +49 08 191 96 52-0, fax: +49 08 19196 52-16, [email protected], www.erdwich.de

System Drauschke

The waste treatment plant consists of a stationaryautoclave and a supply unit. On request, thecompany supplies it as a mobile unit. Theautoclave is a double-walled pressure vessel withcapacity of about 13 m³. It can be sealed in apressure and vacuum tight way by means of aspecial closure. For loading and unloadingpurposes, the cylindrical container can be tiltedin a horizontal direction.

Infectious waste is placed in special paper bagswith a plastic lining. Liquid wastes are placed inpolystyrene drums. The bags and drums areplaced in lockable container, and put intoautoclave chamber. The autoclave processdisinfects the infectious waste by applying a totaltemperature of 121°C and a pressure of 2.1 bar.To avoid the so-called ”cold air islands” in thewaste, a fractionated vacuum process is appliedin which the disinfection chamber is evacuatedseveral times, and subsequently the steam isinjected. The disinfection process is fullyautomatic. After treatment the waste is disposedof in a landfill.

On a client order the company delivers ashredder and compactor.

System Drauschke is approved disinfectingprocesses under §10c of the German EpidemicsControl Act. Further, it fulfils the requirements ofthe European Norm EN 285 for large sterilisators.


The Drauschke System was operating inGermany at various sites (Hamburg, Berlin,Thüringen) in the 1990s. There are no plantsworking in Germany today but since 2003 thereis one ‘System Drauschke’ operating in Slovenia.


Capital costs: 500 – 600 000 EUR.


Stage of commercialisation: Commercialised;during reorganisation.

Vendor’s contact: GÖK Consulting AGAm Schlangengraben 20, 13597 Berlin, Germanytel.: +49 30 351 99 680, fax: +49 30 351 99 640,[email protected], www.goek-consulting.de

WEBECO

WEBECO treatment system operates according tothe advance vaccum/steam-vacuum (VSV)principle. The characteristics of the VSV processare as follows: Removal of existing air from thepressure chamber and the waste introduced berepeated evacuation and subsequent filling withsaturated steam; sterilisation in an environmentof saturated steam at a temperature of 134°C anddrying of sterilised waste by applying a vacuum.

The WEBECO offers a wide range of differentsizes of VSV (vacuum/steam/vacuum)autoclaves: The EC line autoclaves are designedfor the on-site treatment, and match the needs oflaboratories, clinics and hospitals. The EC-Line isavailable with chamber size of 279/439/573/840litres. Depending on the density of the waste andthe chosen chamber, between 15-80 kg infectiouswaste can be treated in these autoclaves.

The 2000 line is for disposal of waste originatingfrom companies or large hospitals. The high-dutyautoclaves are especially designed for thetreatment of large quantities of infectious waste.The 2000 line is available with chamber sizes of1,84/3,75/6,21 m3. These autoclaves are able totreat 100-500 kg infectious waste per hour.


Capital costs: depending on the size.

Technical information: Temperature: 134°C;pressure: 3.1 bar; time of exposure: 15 – 30minutes.


Vendor’s contact: WEBECO GmbH & Co. KG,Mühlenstraße 38, D-23611 Bad Schwartau,Germany, tel: +49 (0) 451 280 72-0,fax: +49 (0) 451 280 72-53, [email protected],www.webeco.com.

ZDA-M3

Contaminated medical waste is put into theplant, crushed by a cutter, and disinfected withhot steam. The disinfecting temperature isrequired to be 105°C, but it is possible to set ahigher temperature up to 140°C. The disinfectingperiod lasts 15 minutes. The plant is controlledby computer; the temperature, pressure anddisinfection (sterilisation) period can be set toindividual requirements.

The mobile ZDA-M3 plant, type II, manufacturedby Maschinenvertrieb für Umwelttechnik GmbHand approved and certified in the Germany(according to BGA-Liste, Section 10c BSeuchG), isused to disinfect medical waste in Slovenia.ZDA-M3 is also certified for use in Switzerland,Spain and New York, USA, and approval hasbeen applied for in France, Italy and Benelux4.The autoclave also operates in Rybnik, Poland,where it serves the needs of the town’s hospitaland medical practices.

Capacity: Approx. 90 kg/h (1.1 m3).

Capital costs: Not specified.

Technical information: Temperature: 105°C(higher temperature possible); pressure: 5 bar;exposure time: 15 minutes.


Vendor’s contact: User in Slovenia: Mollier,Opekarniška 3, 3000 Celje, Slovenia;tel.: +386 3 42 88 400, fax: +386 3 42 88 402,[email protected], www.mollier.si


MICROWAVE SYSTEMS

Microwave disinfection is essentially a steam-based process in which disinfection occursthrough the action of moist heat and steamgenerated by microwave energy.

Microwaves are very short waves in theelectromagnetic spectrum. They fall in the rangeof the radio frequency band, above ultra-highfrequency (UHF) used for television and belowthe infrared range. A magnetron is used toconvert high voltage electrical energy intomicrowave energy, which is then transmittedinto a metal channel called a waveguide thatdirects the energy into a specific area (such asthe cooking area of a microwave oven or thetreatment section of a disinfection unit).

In general, microwave systems consist ofa disinfection area or chamber into whichmicrowave energy is directed from amicrowave generator (magnetron). Typically,2 to 6 magnetrons are used with an output ofabout 1.2 kW each. Some systems are designedas batch processes and others are semi-continuous. The microwave treatment systemsthat have successfully established itself in thealternative technology market in Europe areEcostéryl, Medister, Sanitec, Sintion, Sterifant.

HOW IT WORKS

The operation of a microwave unit (based ona Sanitec Microwave system) is as follows:

• Waste loading: Red bags are loaded intocarts that are attached to the feedassembly. High temperature steam is theninjected into the feed hopper. While air isextracted through a HEPA filter, the topflap of the hopper is opened and thecontainer with waste is lifted and tippedinto the hopper.

• Internal shredding: After the hopper flap isclosed, the waste is first broken down in thehopper by a rotating feed arm and thenground into smaller pieces by a shredder.

• Microwave treatment: The shredded particlesare conveyed through a rotating conveyorscrew where they are exposed to steam thenheated to between 95°C and 100°C by four orsix microwave generators.

• Holding time: A holding section ensures thatthe waste is treated for a minimum total of30 minutes.

• Optional secondary shredder: The treatedwaste may be passed through a secondshredder breaking it into even smaller pieces.This is used when sharps waste is treated.The optional secondary shredder can beattached in about 20 minutes prior tooperation. It is located at the end of a secondconveyor screw.

• Discharge: The treated waste is conveyedusing a second conveyor screw or auger,taking waste from the holding section anddischarging it directly into a bin or roll-offcontainer. The bin can be sent to acompactor or taken directly to a sanitarylandfill.


The types of waste commonly treated inmicrowave systems are identical to those treatedin autoclaves and retorts: cultures and stocks,sharps, materials contaminated with blood andbody fluids, isolation and surgery wastes,laboratory wastes (excluding chemical waste),and soft wastes (gauze, bandages, drapes,gowns, bedding, etc.) from patient care. Withsufficient time and temperature, as well as themechanical systems to achieve unrecognisability,it is technically possible to treat humananatomical wastes but ethical, legal, cultural,and other considerations preclude theirtreatment.

Volatile and semi-volatile organic compounds,chemotherapeutic wastes, mercury, otherhazardous chemical wastes, and radiologicalwastes should not be treated in a microwave.


Studies5 by a laboratory group in Connecticut, aresearch lab in London, and a research institutein Lyon (France) indicated that aerosol emissionsare minimised by the design of the Sanitec unit.

If waste streams are not properly segregated toprevent hazardous chemicals from being fed intothe treatment chamber, toxic contaminants willbe released into the air, condensate, or in the


treated waste. An independent study6 by theNational Institute for Occupational Safety andHealth (NIOSH) found no volatile organiccompounds (VOCs) in a worker’s personal airspace and work area at a microwave facility thatexceeded permissible exposure limits set by theOccupational Safety and Health Administration.The highest VOC level in the autoclave facilitywas 2-propanol, measured at 2318 mg/m3.


A microbiological study7 on treated waste from amicrowave unit showed no growth of micro-organisms (corresponding to a 7 log10 kill orbetter) for the following test organisms: Bacillus

subtilis, Pseudomonas aeruginosa, Staphlococcus

aureus, Enterococcus faecalis, Nocardia asteroides,

Candida albicans, Aspergillus fumigatus,

Mycobacterium bovis, Mycobacterium fortuitum, andduck hepatitis. No growth was also shown(greater than 3 log10 kill) for Giardia miura. Otherstudies8 show the efficacy of microwavedisinfection for other micro-organisms undermoist conditions.


OF THE TECHNOLOGY

Microwave technology has the followingadvantages:

• Because many people have microwaveovens, it is easy for hospital staff andcommunities to understand and accept thetechnology.

• It is accepted or approved as an alternativetechnology, and several dozen units havebeen in operation for many years.

• If proper precautions are taken to excludehazardous material, the emissions frommicrowave units are minimal.

• There are no liquid effluents from the Sanitecmicrowave unit.

• The internal shredder reduces waste volumeup to 80%.

• The technology is automated and easy to use.It requires one operator.


• If hazardous chemicals are in the waste, thesetoxic contaminants are released into the air orremain in the waste to contaminate thelandfill.

• There may be some offensive odours aroundthe microwave unit.

• The secondary shredder used for sharps isnoisy.

• Any large, hard metal object in the wastecould damage the shredder.

• The capital cost is relatively high.

EXAMPLES OF MICROWAVES SYSTEMS

Ecostéryl

The Ecostéryl process consists of grinding andheating wastes at the temperature of 100°C.The weight of waste is automatically checked,then it is packed into 750 litres containers andautomatically handled and dumped into thehopper. The loading hopper includes a disinfectantspray system and a suction device to create a partialvacuum when it is opened. Treatment of air bywashing, disinfecting, deodorising and filtrationover activated charcoal, preserves the quality ofrejected air. City water is fed through a non-returnvalve thereby preventing any fluid returning tothe drinking water system. The liquid disinfectant(Dial Danios) is automatically dosed and pumpedinto the system.

Before the heat treatment phase begins, wastesare shredded by a knife mill with a grille totransfer waste into granules ranging in size from1.5 to 2.0 cm. The mill’s automatic control systemincludes an automatic anti-blocking device. Aftergrinding, wastes are handled by screws andmoisturised. The ground-up wastes are conveyedthrough an enclosed space and subjected tomicrowaves, which ensure in-depth heating andwaste decontamination. The time of transferinto the treatment screw is on the order of3 min. To improve disinfection level, waste iskept at a 500 litre buffer hopper for 1 hour.Disinfected wastes are then picked up underthe holding hopper by an Archimedes screwand carried into a 45 litre hopper. Using the


large exchange surface of the screw wastes arecooled to about 60 - 70°C. Volume of wastes isreduced by a factor of 5 and even more.

Several Ecostéryl medical waste decontaminationunits are used in Europe.

Capacity: 250 kg/h.


Technical information: Temperature: 100°C; timeof exposure: 60 minutes.


Vendor’s contact: AMB S.A., Avenue Wilson 622,7012 Mons, Belgium; tel.: + 32 658 226 81,+32 658 247 98; [email protected]

Medister

The Austrian company Meteka supplies Medisterunits suitable for the decontamination ofinfectious waste using microwave action.The Medister 10, 60, and 160 types differ in thecapacity of waste processed and allow variouskinds of infectious waste to be disinfected.Medister 360 is designed to sterilise highlyinfectious material and waste from researchlaboratories using genetically modifiedorganisms where perfect destruction of thebiological agent is necessary.

Meteka also supplies a mobile microwave unitwhich consists of three Medister 160 wastedisinfection devices. Within an 8 hour shift theunit may disinfect 36 Meditainer wastecontainers (2160 litres).

Medister HF is another waste sterilisation deviceand operates using domestic service water.Water, heated by high-frequency energy, istransformed into steam in the unit.The manufacturer specifies that the equipment isefficient in destroying Bacillus stearothermophilus

spores exceeding 106 (6 log10).9

Capacity: 6-60 l/cycle.

Capital costs: 10 000 - 70 000 EUR.

Technical information: Temperature: 110/121/134°C; one operational cycle: 45 minutes.

Stage of commercialisation: Commercialised, inoperation since 1991.

Vendor’s contact: Burgasse 108, 8750 Judenburg,Austria, tel.: +43 3572 85166, fax: +43 3572 85166 6,[email protected], www.meteka.com

Sanitec

Sanitec microwave system consists of anautomatic charging system, hopper, shredder,conveyor screw, steam generator, microwavegenerators, discharge screw, secondary shredder("particliser"), and controls. The equipmentincludes hydraulics, high efficiency particulateair filter (HEPA), and microprocessor-basedcontrols protected in an all-weather steelenclosure.

According to the manufacturer’s informationtwo Sanitec units are installed in the ChaseFarm Hospital in Enfield, Middlesex, andoperated by Polkacrest / LondonWaste.The yearly capacity of these two plants is 3600tonnes. In addition to Enfield there are otherunits installed in Great Britain. Sanitec iscertified for operation in the followingEuropean countries: France, Germany, Ireland,Great Britain, Spain, and Switzerland. OutsideEurope, Sanitec plants are installed in:Australia, Brazil, Canada, USA, India, Japan,Kuwait, Philippines, Saudi Arabia, South Africa,and South Korea.


Capital costs: 420-500 000 EUR.

Technical information: Temperature: 95 – 100°C;exposure time: 30 minutes.


Vendor’s contact: Sanitec Group LLC, 59 VillagePark Road, Cedar Grove, NJ 07009, USA,tel.: +1 973 227 8855, fax: +1 973 227 9048


Sintion

Sintion is a microwave unit intended for a smallwaste quantity. It can be installed near the placeof waste origin.

Waste is put in a vapour-permeable bag thatallows steam to penetrate to the waste. Doublebags or closed containers should not be used;puncture-resistant containers for sharp objectsshould not be hermetically closed. The operatoropens the cover and inserts a bag filled with wasteinto the disinfecting chamber (one bag per cycle).The waste surface is exposed to the action of thesteam, and the microwave radiation heats thewaste from inside, destroying micro-organisms.

The temperature in the disinfecting chamber is121°C and, if required, can be increased to 134°C.The period of the microwave radiation action canalso be set to individual requirements.The disinfecting process usually lasts 10 to 30minutes depending on the temperature selected.

After the end of the disinfecting cycle waste canbe taken out and processed further in a crusheror in a compactor.

The Sintion unit was tested and accepted assuitable technology by the Robert Koch Institutein Germany, received a TÜV certificate inAustria, and was authorised for use in NewYork, USA. On its internet pages the companyalso refers to other tests performed andcertificates obtained in other countries.10

Capacity: Up to 35 kg/h.


Technical information: Temperature: 121/134°C;pressure: 0.5 bar; time of exposure: 10 – 20minutes.

Stage of commercialisation: Commercialised, inoperation since 1995.

Vendor’s contact: CMB Maschinenbau undHandels GmbH, Plabutscherstr. 115, 8051 Graz,Austria, tel . : +43 316 685 515-0,fax: +43 316 685 515-210, [email protected],www.christof-group.at

Sterifant 90/4

Wastes are collected in specially designed,reusable, hermetically sealed polycarbonate bins.The bins designed for the system are reusable upto 500 times. The lids are reusable byreplacement of the “bung” after each treatment.The bin has a sealing clamp ring placed over thelid joint and locked shut forming a hermetic seal.The full and sealed bins can be easily stacked.

For each cycle 10 bins are put into sealedtreatment chamber. The cycle begins with 10hollow needles being lowered into the lids of thecontainers puncturing the “bung” seal of the lids.A washer around the hollow needles then formsa pressure seal, connecting each of the 10 bins tothe system for treatment to begin.

At the start of the treatment cycle, approximately2 litres of water and steam at 140°C are injectedthrough the hollow needles into each of the bins.The system’s nine microwave generators are thenactivated, heating the contents of the bins to atemperature in excess of 105°C, which ismaintained, causing a saturated steamatmosphere. Creating first a vacuumed and thenpressured atmosphere within each of the binsfurther increases the unit’s effectiveness.

At the end of the cycle the treatment chamber of theunit opens automatically. Bins are then transferredto the integral shredder located at the side of theunit. The content of the bins is emptiedautomatically into the shredder. The shreddedwastes are compacted at 80 bars pressure, and anyliquid present is drawn off to the separate tank.The disinfecting process last about 70 minutesdepending on the waste characteristics. The volumeof wastes treated is reduced by up to 80%.

The system can be used as a mobile or staticsystem for treatment of health care wastes onsite. In Germany the Sterifant system wasaccepted in 1995, onto the approval list of theRobert-Koch Institute at the Ministry of Health.

Sterifant system units are used in Germany,Hungary, France, Netherlands, Italy, Spain, GreatBritain, Bulgaria, Portugal.

Capacity: Approx. 125 kg/h.

Capital costs: 391 400 EUR (stationary), 446 400EUR (mobile).


Technical information: Temperature: 95 – 105°C;time of exposure: 70 minutes.


Vendor’s contact: Sterifant Vertriebs GmbH;12, Rue Jean Engling, L-1466 Luxembourg;tel.: +352 43 22 22-1, fax: +352 42 60 59,[email protected], www.sterifant.com

1 K. Owen, K. Leese, L. Hodson, R. Uhorchak, D.Greenwood, D. Van Osdell, and E. Cole. “Control ofAerosol (Biological and Nonbiological) and ChemicalExposures and Safety Hazards in Medical WasteTreatment Facilities.” (Cincinnati, OH: National Instituteof Occupational Safety and Health, November 1997).

2 See for example: J.L. Lauer, D.R. Battles, and D.Vesley, “Decontaminating infectious laboratory wasteby autoclaving,” Appl. Envron. Microbiol., 1982, 44 (3),690-694; W.A. Rutala, M.M. Stiegeland, and F.A.Sarubbi, Jr., “Decontamination of laboratorymicrobiological waste by steam sterilization,” Appl.

Environ. Microbiol., June 1982, 43, 1311-1316. E. Hanel,Jr., “Chemical Disinfection” in Control of Biohazards in

the Research Laboratory, Course Manual, School ofHygiene and Public Health, Johns Hopkins University,Baltimore, MD, 1981; Herman Koren, Environmental

Health and Safety, Pergamon Press, NY, 1974.

3 Based on information from www.ecodas.com

4 Based on information leaflets: Mobile disposal ofinfectious waste, Maschinenvertrieb fürUmwelttechnik, GmbH, Germany.

5 Evaluation of the ABB Sanitec MicrowaveDisinfection System for Aerosol Emissions, NorthAmerican Laboratory Group, New Britain, CT, 1992;ABB Sanitec Microwave Disinfection System - Abilityto Control Aerosol Emissions: Synopsys of Evaluation,a summary of aerosol emissions studies provided bySanitec, November 1, 1996.

6 E. Cole. “Chemical and Biological Exposures andSafety Hazards in Medical Waste Treatment Facilities:An Assessment of Alternative Technologies.” Vol.98/2, No. 9 (Cedex, France: International HealthcareWaste Network (IhcWaN), August 31, 1998).

7 Copy of “ABB Sanitec Microwave Disinfection SystemLaboratory Test Results” from North American LaboratoryGroup and Stanford University, provided by Sanitec.

8 G.R. Vela and J.F. Wu, Appl. Environ. Microbiol., 37(3),552, 1979; L. Najdovski, A.Z. Dragas, and V. Kotnik, J.Hosp. Infect. (19), 239, 1991.

10 http://www.christof-group.at/www/en/cmb/zertifikate.php


Chapter 6

Low-heat thermal technologies – dry heat systems

Just as circulating hot-air ovens have been usedto sterilise glassware and other reusableinstruments, the concept of dry heat disinfectionhas been applied to treatment of medical waste.In dry heat processes, heat is applied withoutadding steam or water. Instead, the waste isheated by conduction, natural or forcedconvection, and/or by thermal radiation. In forceconvection heating, air heated by resistanceheaters or natural gas, is circulated around thewaste in the chamber. In some technologies, thehot walls of the chamber heat the waste throughconduction and natural convection. Othertechnologies use radiant heating by means ofinfrared or quartz heaters. As a general rule, dryheat processes use higher temperatures andshorter exposure times than steam-basedprocesses, but the time-temperature requirementsactually depend on the properties and size of theobjects being treated.

The toroidal mixing bed dryer using highvelocity heated air (a technology designed forhospitals and offered by KC MediWaste) and theDemolizer (a small table-top device for hospitaldepartments, clinics, medical offices, and othersmall volume generators) are two examples ofdry heat systems in use, mainly in the USA.

OVERVIEW OF THE TECHNOLOGY

KC MediWaste System evolved out of efforts byCox Sterile Products, Inc. to develop a rapid dryheat sterilizer coupled with their adaptation ofthe Torbed technology by Torftech (UK), a dryheat technology used in the processing ofminerals, foods, and wastes. The first installationof the KC MediWaste technology is at the MercyHealth Center in Laredo, Texas.

The heart of the system is an air-tight stainlesssteel chamber into which shredded medicalwaste is introduced and exposed to high velocityheated air pumped into the bottom of thechamber through a ring of vanes or slots similarin design to turbine blades. The hot air is directedin a way that causes the waste particles to rotate

turbulently around a vertical axis in a toroidalmixing action. Under these conditions, high ratesof heat transfer take place. Within four to sixminutes, dry unrecognisable waste is ejected. Thewaste can then be disposed of at a regularlandfill.

HOW IT WORKS

The operation of the KC MediWaste System is asfollows:

• Waste loading: Red bags are loaded into cartsthat attach to a lifter-dumper whichautomatically opens an air-lock hopper doorand empties the waste into the shredderhopper while maintaining a negative pressureto minimise aerosolisation.

• Internal shredding: The waste is shredded to arelatively uniform size of about 19 mm,passing through a changeable screen andcollected in a surge vessel.

• Metering: A gate valve controls the amount ofwaste introduced into the chamber. Thisopens automatically when the chamber isempty allowing a new batch to be processed.The chamber operates under a negativepressure.

• Dry heat treatment: After the shredded wasteis pulled into the chamber it is exposed tohigh-velocity heated air (at about 171°C). Thetemperature in the chamber drops initially butrecovers in about four minutes.

• Discharge: At the end of a pre-set time, thedump door of the chamber is openedexpelling the waste in a matter of seconds.The treated waste falls into a compactordumpster under the chamber.

• Compaction and disposal: The dry,unrecognisable waste is compressed and putinto sealed containers ready for disposal at asanitary landfill.



The types of waste treated in the KCMediWaste System are somewhat similar tothose treated in autoclaves or microwaves:cultures and stocks, sharps, materialscontaminated with blood and body fluids,isolation and surgery wastes, laboratory wastes(excluding chemical waste), and soft wastes(gauze, bandages, drapes, gowns, bedding,etc.) from patient care. In addition, liquids suchas blood and body fluids can also be treated inthe unit. It is technically possible to treathuman anatomical wastes but ethical, legal,cultural, and other considerations precludetheir treatment in this technology.

Volatile and semi-volatile organic compounds,chemotherapeutic wastes, mercury, otherhazardous chemical wastes, and radiologicalwastes should not be treated in a dry heatsystem.


Exhaust gases from the air pulled from theshredder hopper are filtered through a highefficiency particulate air filter (HEPA) and acarbon filter to remove aerosolised pathogensand odours prior to discharge. The hot air fromthe chamber is cooled in a venturi scrubberwhich also removes particulates. There are someodours in the vicinity of the unit.

The conditions in the chamber do no supportcombustion. Therefore, the air emissions areminimal as long as waste streams are properlysegregated to prevent hazardous chemicals frombeing fed into the chamber.

The waste residue is dry and unrecognisable.With shredding and compaction, the wastevolume is reduced by about 80% and has beenaccepted for disposal at a regular landfill. Themass of the dry treated waste is also reduceddepending on the amount of moisture it hadcontained.


Microbiological tests using B. subtilis var. niger

strips (the variety traditionally used to test fordry heat resistance) introduced into the chambershowed a 6 log10 kill in about three minutes.1


OF THE TECHNOLOGY

Heated air technology has the followingadvantages:

• The basic design of the treatment chamber issimple (it has been described as a ‘popcorn’popper). The Torbed itself has been used formany years in other applications.

• If proper precautions are taken to excludehazardous material the emissions from thedry heat system are minimal.

• The technology can treat waste with varyingmoisture content including blood and bodyfluids.

• There are no liquid effluents.

• The internal shredder and post-treatmentcompactor reduce waste volume by about80%.

• The technology is automated and easy to userequiring only one operator.

• A combination of HEPA, carbon filters and aventuri scrubber keep odours to a minimum.

• The treated waste is dry, unrecognisable, andcompact.


• If hazardous chemicals are in the waste, thesetoxic contaminants are released into the air orremain in the waste to contaminate thelandfill.

• Some slight odours may be generated nearthe compactor.

• Any large, hard metal objects may interferewith the shredder.

• The KC MediWaste Processor is a relativelynew technology.

1 Data provided by KC Mediwaste.


Chapter 7

Chemical based technologies

In the past, the most common chemicaldisinfectants for treating medical waste werechlorine-based because of the ability of chlorineand hypochlorite to inactivate a broad range ofmicro-organisms. Solutions of sodium hypochlorite(bleach) were regularly used. In recent yearshowever, concerns have been raised about smallamounts of toxic by-products associated with theuse of large quantities of chlorine and hypochlorite(such as in the pulp and paper industry).Apparently, no studies have been done to establishwhether or not this problem exists downstream ofchemical treatment facilities for medical waste. It isbelieved however, that reactions betweenchlorine/hypochlorite and organic matterproduce trihalomethanes, haloacetic acids, andchlorinated aromatic compounds that are toxic.

Sodium hypochlorite (NaOCl), a commonlyused disinfectant in health care facilities, ismanufactured by reacting chlorine with sodiumhydroxide and water. Household bleach is a 3%to 6% concentration of sodium hypochlorite. It iseffective in inactivating bacteria, fungi, andviruses, and in controlling odour. It is usedextensively as a disinfectant for drinking water,swimming pools, and sewage treatment.Not surprisingly, it was one of the first chemicaldisinfectants to be used in treating medicalwaste.

Recently, non-chlorine chemical disinfectantshave been introduced into the market, such asperoxyacetic acid (also known as peracetic acid),glutaraldehyde, sodium hydroxide, ozone gas,and calcium oxide. Some of these are commonlyused in disinfecting medical instruments.

Calcium oxide, also called lime or quicklime, is awhite or grey odourless powder produced byheating limestone. It has a myriad of uses inmedicines, water softeners, cements, glassmaking, purifying sugar, and treating soils. Itreacts with water to form calcium hydroxide andcan irritate the eyes and upper respiratory tract.The US NIOSH recommended exposure limit is2 mg/m3.

Ozone is an oxidising agent that contains threeatoms of oxygen (O3) rather than the usual two(O2). Trace amounts of ozone are formed by thesun or when lighting strikes. It is a component ofsmog and also makes up a protective layeraround the earth. Because it is highly reactive, itbreaks down easily back to its more stable form(O2). Ozone is used in drinking water treatment,industrial and municipal wastewater treatment,odour control, air purification, agriculture, andfood processing. Ozone can cause eye, nose, andrespiratory tract irritation. According to USNIOSH, workplace air should not have morethan 0.1 ppm of ozone.

Alkali or caustic, such as sodium or potassiumhydroxide, are extremely corrosive. They areused in chemical manufacturing, pH control,soap production, cleaners, textile processing, anda wider range of other uses. Solid cakes or pelletsof the alkali react strongly with water releasingheat. Contact with various chemicals includingmetals may cause fire. Concentrated alkalinesolutions are corrosive enough to causepermanent scarring, blindness, or even death.Aerosols of the alkali can cause lung injury.The US NIOSH recommended exposure limit is2 mg/m3.


The types of waste commonly treated inchemical-based technologies are: cultures andstocks, sharps, liquid human and animal wastesincluding blood and body fluids (in sometechnologies this may be limited to a certainpercentage of the waste), isolation and surgerywastes, laboratory waste (excluding chemicalwaste), and soft wastes - gauze, bandages,drapes, gowns, bedding, etc., from patient care.

Ethical, legal, cultural, and other considerationspreclude treatment of human anatomical wastesin chemical treatment systems.

Volatile and semi-volatile organic compounds,chemotherapeutic wastes, mercury, other


hazardous chemical wastes, and radiologicalwastes should not be treated in chemicaltreatment units. Large metal objects may damageinternal shredders.


Since chemical processes usually requireshredding, the release of pathogens throughaerosol formation may be a concern. Chemical-based technologies commonly operate as closedsystems or under negative pressure passing theirair exhaust through HEPA and other filters.These safeguards should not be compromised.Another issue relates to occupational exposuresto the chemical disinfectant itself throughfugitive emissions, accidental leaks or spills fromstorage containers, discharges from the treatmentunit, volatilised chemicals from treated waste orliquid effluent, etc. Chemical disinfectants aresometimes stored in concentrated form thusincreasing the hazards.


Micro-organisms vary in their resistance tochemical treatment. The least resistant arevegetative bacteria, vegetative fungi, fungalspores, and lipophilic viruses. The more resistantorganisms are hydrophilic viruses, mycobacteria,and bacterial spores such as B. stearothermophilus.

Tests of microbial inactivation efficacy should beconducted to show that a 104 kill or greater of atleast B. stearothermophilus spores is achieved atthe chemical concentrations and treatmentconditions of normal operation of the technology.


OF THE TECHNOLOGY

Chemical treatment technologies have thefollowing advantages:

• The technologies using sodium hypochloritehave been used since the early 1980s and havea long track record. The process is wellunderstood.

• The technologies are well automated andeasy to use.

• Liquid effluents generally can be dischargedinto the sanitary sewer.

• No combustion by-products are produced.

• If the technology incorporates shredding, thewaste is rendered unrecognisable.


• There are concerns of possible toxic by-products in the wastewater from large-scalechlorine and hypochlorite systems.

• Chemical hazards are a potential problemwith chemical-based systems.

• If hazardous chemicals are in the waste, thesetoxic contaminants are released into the airand wastewater, remain in the waste tocontaminate the landfill, or they may reactwith the chemical disinfectant forming othercompounds that may or may not behazardous.

• Noise levels, such as from a hammermillprocess or a shredder, can be very high.

• There may be some offensive odours aroundsome chemical treatment units.

• Any large, hard metal object in the waste candamage mechanical devices such asshredders.

EXAMPLES OF CHEMICAL BASED TECHNOLOGIES

Newster

The Newster is a machine designed for small andmedium hospitals. Technology combines thermaland chemical processes to sterilise waste.

In a closed sterilisation vessel a powerful rotorfitted with blades agitates, disintegrates andheats the wastes by impact and friction. Thewastes are sprayed with 14% – 15% strengthNaClO. When the temperature reaches thepredetermined level of 150°C, the mass of wastesis automatically sprayed with brief injections ofwater so that the temperature remains above150°C for around two minutes.

During the process, the high temperature meltsplastic materials and the wastes are transformedinto granules of a uniform grayish-brown colour,with average dimensions of 2 – 3 mm.

The treated wastes are then cooled down to 95°Cat which point the cycle has been completed andwastes, by now sterile, are automatically unloaded.The whole process lasts around 20 minutes.


The vapours released by the evaporation ofliquids are absorbed by a flow of watercontaining sodium hypochlorite inside a columnconnected to the sterilisation vessel. To dispersethe heat produced by the system, part of thewater is continuously replaced by fresh waterfrom the main supply. Excess water andincondensable gases are discharged into thesewers.

The use of chlorine-based disinfectants can causea risk of chloride’s presence in the wastedecontaminated, and the creation of the newtoxic chlorine compounds (i.e. trihalomethane).

Capacity: 370 t/a.


Technical information: Temperature: 95 - 155°C;time of exposure: 25 minutes; amount of NaClOuse per cycle: 0.3 – 0.5 kg.


Vendor’s contact: Multiservice First s.r.l.; Via deiBoschetti 58/A, 47893 Borgo Maggiore, Republicof San Marino; tel.: +378 0549 907 222,fax +378 0549 907223, [email protected],www.tradecenter.sm/newster/

Waste Reduction By Waste Reduction, Inc.1

or WR2

Waste Reduction by Waste Reduction Inc.,offers an alkaline digestion process to convertanimal and microbial tissues into a neutral,decontaminated, aqueous solution. The WR2

process utilises alkaline hydrolysis at elevatedtemperatures. The alkali also destroys fixativesin tissues and various hazardous chemicalsincluding formaldehyde and glutaraldehyde.2

The Tissue Digester is an insulated, steam-jacketed, stainless steel tank with a retainerbasket for bone remnants and a clam-shell lid.After the waste is loaded in the hermeticallysealed tank, alkali in amounts proportional to thequantity of tissue in the tank is added along withwater. The contents are heated, usually tobetween 110° to 127°C or up to about 150°C,while being stirred. The tanks are rated at 6.1 barbut are operated at less than 4.8 bar Dependingon the amount of alkali and temperature used,

digestion times range from three to six hours.The technology does not handle the full range ofwaste streams in a health care facility, but isdesigned for tissue wastes including anatomicalparts, organs, placentas, blood, body fluids,specimens, degradable bags, degradable fabrics(such as Isolyser’s Orex and Enviroguard), andanimal carcasses. Antineoplastic (cytotoxic)agents can also be destroyed by the strongalkali.

Capacity: 15 – 4500 kg/cycle.

Capital costs: 100 000 – 830 000 EUR.

Technical information: Temperature: 110 - 127(150) °C; pressure: 4.8 bar; time of exposure: 3 - 6hours.

Stage of commercialisation: Commercialised inthe US since 1993; awaits approval for the EUmarket.

Vendor’s contact: Waste Reduction by WasteReduction Europe Ltd.; Clydebank RiversideMedi-Park, Beardmore Street, Clydebank,Glasgow G81 4SA, UK; tel.: +44 141 951 5980,fax: +44 141 951 5985; [email protected];www.wreurope.net

Steris EcoCycle 103

It is a compact system designed to treat smallvolumes and can be used at or near the point ofgeneration of waste. It treats 2 to 4 kg of wasteevery 10 minutes including syringes, needles,glassware, laboratory waste, blood, other bodyfluids, specimens, cultures, and othercontaminated materials.

The waste is collected in a portable processingchamber at the point of generation. When filled,the chamber is transported to a processor usingan optional caddy. A peracetic acid-baseddecontaminant in a single-use container isdropped into the chamber (the specificformulation used depends on how much fluid isin the waste). As the processing cycle begins,the material is groundup breaking thedecontaminant vial and chemically disinfectingthe waste in 10 - 12 minutes. The processing capcontains a replaceable HEPA filter to prevent theescape of aerosolised pathogens. At the end of


the cycle, the chamber is put on a tilt bracket andits contents are dumped into the liquidseparation unit. Water is used to rinse the waste.The liquid effluent is filtered before beingdischarged into the sewer drain, while the wasteis retained in the liquid separation unit fordisposal as regular trash. The chemical by-products of the decontaminant are acetic acidand some hydrogen peroxide which eventuallybreak down into a weak vinegar solution.Microbial inactivation tests4 demonstrate a 6 to 8log10 kill for 13 micro-organisms including B.

subtilis, Staphylococcus aureus, Pseudomonas

aeruginosa, bacteriophage MS-2, Mycobacterium

bovis, Poliovirus, Aspergillus fumigatus, Candida

albicans, and Giardia muris. Steris markets itsdecontaminant in two doses: STERIS-SW mainlyfor solid wastes with low organic load, andSTERIS-LW for waste with high amounts ofliquids and a high organic load.



Technical information: Time of exposure:12 minutes.


Vendor’s contact: 5960 Heisley Road, Mentor, Ohio44060-1834, USA; tel.: +1 440-354-2600, fax: +1 440639 4450; www.steris.com

OTHER SYSTEMS

Not included in this report are technologies thatuse chemical compounds not necessarily for theirdisinfecting potential, but for their ability tosolidify or encapsulate waste. Someencapsulating agents are fast-acting acrylic orepoxy-based polymers incorporating anti-microbial agents to disinfect the waste. Manyclaim to be non-toxic and to reduce bio-hazardous fluids into non-hazardous materials.

Health care facilities interested in thesetechnologies should ask for the results ofmicrobial inactivation efficacy tests, toxicity tests,occupational exposure tests, etc. to ascertainclaims that the resulting solidified waste isindeed disinfected and non-hazardous. Becauseorganic material in liquid medical waste canreduce anti-microbial effectiveness, tests fordisinfection should be conducted using 100%

serum at the use dilution specified on theproduct label. Interested facilities should alsocheck whether the solidifying and sanitisingagents are themselves hazardous substances andwhether the resulting encapsulated waste can bedisposed in a landfill. However, although suchwaste can be considered as ‘treated’, it may stillhave infectious properties and hence cannot belandfilled according to the European Unionlegislation (Directive 99/31/EC).

1 Based on vendor website, brochures and technicaldata provided by WR2.

2 Data provided by Dr. Gordon Kaye, WR2.

3 Based on vendor website, literature provided byEcomed beginning in 1993 and by Steris from 1995 to1999, and personal communications with various Sterispersonnel.

4 W.L. Turnberg. Biohazardous Waste: Risk Assessment,

Policy and Management. (New York, NY: John Wiley &Sons, Inc. 1996).


Chapter 8

Irradiation, biological and other technologies

This chapter discusses other technologies thatuse irradiative and biological processes. Thepresentation on irradiation technology focuses onelectron beam systems. There have been very fewbiological systems designed for medical wastetreatment as this technology is still in the researchand development phase. Because occupationalinjuries from needles and syringes are a problemin health care facilities, a discussion of sharpswaste treatment technologies is presented at theend of this chapter. Sharps technologies are smallportable units that operate on the principles ofthermal or chemical treatment.

Irradiation Technologies

OVERVIEW OF THE TECHNOLOGY

When electromagnetic radiation has high enoughenergy to knock out electrons from their atomicorbits, it is referred to as ionising radiation;examples are x-rays and gamma rays. (Non-

ionising radiation, such as microwaves andvisible light, do not have sufficient energy toremove electrons.) If ionising radiation interactswith a cell, its main target is the DNA in thenucleus. At sufficiently high doses of ionisingradiation, extensive damage is done to DNAleading to cell death. The ionising radiation alsocreates so-called free radicals that cause furtherdamage by reacting with macromolecules in thecell (e.g., proteins, enzymes, etc.). Ionisingradiation can be obtained using radioactivematerials, such as Cobalt-60, that emit high-speed gamma rays. UV-C or ultraviolet radiationin the C range (253.7 nm), also known asgermicidal or short wave UV, is another kind ofionising radiation that can destroy cells under theproper conditions. UV-C can be generated usingspecial lamps and has been employed as asupplement to alternative treatment technologiesto inactivate aerosolised pathogens fromshredders and other mechanical devices.

Another technique for producing ionisingradiation is to use an “electron gun” from whicha beam of high-energy electrons is propelled at

high speed to strike against a target. A product ofthe nuclear and defence industries, electron beam(or e-beam) technology has been around for afew decades. It is also used in other applications,such as polymer processing, tyre manufacturing,and sterilisation of medical products. Unlikecobalt-60, e-beam technology does not useradioactive sources and has no residual radiationonce the e-beam system is turned off. One area ofdebate, however, is the issue of inducedradioactivity. E-beam manufacturers argue thatradioactivity cannot be induced unless very highenergies are used, e.g., above 10 or 16 MeV(mega-electronvolts). Others have stated that lowlevels of radioactivity may be induced at muchlower energies. This argument has arisen in thecontext of the public controversy over foodirradiation using e-beam technology.

HOW IT WORKS

Electron beam technologies are highly automatedand computer controlled. In general, e-beamsystems consist of a power supply; a beamaccelerator where the electrons are generated,accelerated, and directed towards the target; ascanning system which delivers the requireddose; a cooling system to cool the accelerator andother assemblies; a vacuum system to maintain avacuum in the accelerator; a shield to protectworkers; a conveyor system to transport thewaste; and sensors and controls. The shieldingsystem could be in the form of a concrete vault,an underground cavity, or an integral shieldaround the treatment area. E-beams do not alterthe physical characteristics of the waste exceptperhaps to raise the temperature a few degrees.As such, e-beam technologies require shreddersor other mechanical device in the post-processingstage to render the waste unrecognisable andreduce waste volume.


The types of waste commonly treated in an e-beam technology equipped with a mechanicaldestruction process are: cultures and stocks,sharps, materials contaminated with blood and


body fluids, isolation and surgery wastes,laboratory waste (excluding chemical waste), andsoft wastes (gauze, bandages, drapes, gowns,bedding, etc.) from patient care. Ethical, legal,cultural, and other considerations precludetreatment of human anatomical wastes.

Volatile and semi-volatile organic compounds,chemotherapeutic wastes, mercury, otherhazardous chemical wastes, and radiologicalwastes should not be treated in e-beam units.


E-beam systems do not create any pollutantemissions except possibly for small amounts ofozone which breaks down to diatomic oxygen(O2). The residual ozone helps remove odoursand contributes to the disinfection process in thetreatment chamber, but it should be convertedback to diatomic oxygen before being releasedinto the environment or workspace.


Bacteria exhibit varying degrees of resistance toradiation depending in large part on their ability torepair damage to their DNA from irradiation.Depending on the dose, bacterial cells may not bekilled outright but their ability to reproduce isimpaired. B. stearothermophilus and B. subtilis sporeshave been recommended for demonstratingmicrobial inactivation by irradiation. However,B. pumilus spores are more resistant to irradiationand have been used as a standard biologicalindicator in the sterilisation of medical products byirradiation. Other biological indicators even moreresistant to radiation, such as Deinococcus

radiodurans, can provide a very stringent measureand add a margin of safety if needed.


OF THE TECHNOLOGY

E-beam treatment technologies have thefollowing advantages:

• The basic technology has been used in otherapplications for about two decades and isfamiliar to hospital staff involved in cancertherapy.

• E-beam technology does not produce anytoxic emissions (except for small amounts ofozone) and there are no liquid effluents.

• Unlike cobalt-60, there is no ionisingradiation after the machine is turned off.

• It is a room-temperature process and nothingis added to the waste – no steam, water,chemicals, heated air, etc.

• The technology is well automated andrequires little operator time.

• The e-beam technology itself (i.e., excludingshredders or compactors) is noiseless.

• It has a low operating cost.


• Personnel must be protected from radiationexposure.

• If an integral shield is not part of the design,the e-beam system requires a concrete shieldseveral feet thick or an undergroundstructure, either of which adds significantly tothe installed capital cost.

• Ozone off-gas needs to be removed beforethe exhaust is released to the atmosphere.

• In relation to food irradiation. Some groupshave raised the possibility that low-levels ofradioactivity may be induced. This is an areathat needs more investigation.

• The basic technology does not reduce wastevolume or make the waste unrecognisableunless a shredder or other mechanical deviceis added as a post-treatment step.

• Any large, hard metal object in the waste candamage any shredder or grinder.

The University of Miami’s Laboratories for

Pollution Control Technologies,1 in associationwith the UM/Jackson Memorial Medical Center,have developed a high-energy electron beammedical waste treatment facility. This e-beamfacility is capable of treating 180 kg per hour ofmedical waste and uses 0.19 m2 of spaceincluding shielded vault, control room, andwaste holding area.

Biological Systems

Bio Conversion Technologies Inc.2 (BCTI),a division of Biomedical Disposal, Inc., isdeveloping a medical waste treatment systemusing biological processes. A prototype of the


“Bio-Converter” has been tested in Virginia.It uses an enzyme mixture to decontaminatemedical waste and the resulting sludge is putthrough an extruder to remove water for sewagedisposal. The technology is suited for largeapplications (10 tons/day) and is also beingdeveloped for use in the agricultural sector tobreak down animal waste.

Small Sharps Treatment Units

Occupational injuries from needles and syringesare a problem facing all health care providers.It has been estimated that 600 000 to 800 000nurses, physicians and other health careworkers suffer needle stick and otherpercutaneous injuries due to sharps. Not allinjuries result in infections but the transmissionof bloodborne diseases from contaminatedsharps is always a possibility. Three diseases inparticular — Hepatitis C virus (HCV), HepatitisB virus (HBV) and human immunodeficiencyvirus (HIV) — are of great concern. Most ofthese injuries can be prevented by the use ofsafer devices such as needleless systems,devices with retractable or blunt needles, orother so-called safe needle devices with built-insafety features.

Another way of helping to reduce the risk ofneedle sticks is by using sharps waste treatmenttechnologies near the point of use.

1 Based on technical data provided by the university’sLaboratories for Pollution Control Technologies,newspaper clippings, data provided by Dean Brown,site evaluation of the unit at the University of Miami-Coral Gables, and personal communications withThomas Waite and Charles Kurucz.

2 Based on personal communications and materialsprovided by Michael Chelette in 1999.


Chapter 9

Factors to consider in selecting a non-incineration technology

Determining the best technology or combinationof technologies for a particular facility dependson many site-specific factors. These include theamount and composition of waste generated,available space, regulatory approval, publicacceptance, and cost. Some key factors toconsider are listed in Table 9-1 and discussed inthis chapter.

THROUGHPUT CAPACITY

Having determined the rate of waste generationfor the different waste streams and havingimplemented a vigorous waste minimisationplan, the health care facility is now in a positionto select a non-incineration treatment technologyappropriate for the types and amount of waste tobe treated. When matching throughput capacitieswith waste generation rates, the facility should

take into account future anticipated growth andvariables in waste generation.


Broad categories are used to describe the types ofwaste that a technology can handle, generallybased on manufacturers’ recommendations.After determining what goes in a red bag,facilities should make sure that the selectedtechnology can indeed treat each waste categoryfrom the perspective of mechanical destruction,microbial inactivation, emissions, regulatoryacceptance, and safety.

The use of monitoring equipment, such asdevices to detect low-level radioactive waste, canhelp keep specific waste streams out. Sometechnology vendors offer monitoring devices toexclude unwanted materials from the inputstream. Others design their equipment to be ableto interface with such devices.

MICROBIAL INACTIVATION EFFICACY

The main purpose for the treatment technology isto decontaminate waste by destroying pathogens.Facilities should make certain that the technologycan meet state criteria for disinfection. Manycountries require approval of alternativetechnologies based on microbiologicalinactivation efficacy. A consortium of stateregulatory agencies called the (US) State andTerritorial Association on Alternative TreatmentTechnologies (STAATT) met in 1994 and 1998 todevelop consensus criteria for medical wastetreatment efficacy. The first STAATT meetingcame up with the following definitions of thelevels of microbial inactivation:

Level I Inactivation of vegetative bacteria,fungi, and lipophilic viruses at a 6 log10

reduction or greater;

Level II Inactivation of vegetative bacteria,fungi, lipophilic/hydrophilic viruses,parasites, and mycobacteria at a 6 log10

reduction or greater;

Table 9-1. Factors to consider in selectinga technology

� Throughput capacity

� Types of waste treated

� Microbial inactivation efficacy

� Environmental emissions and wasteresidues

� Regulatory acceptance

� Space requirements

� Utility and other installationrequirements

� Reduction of waste volume and mass

� Occupational safety and health

� Noise and odour

� Automation

� Reliability

� Level of commercialisation

� Technology manufacturer/vendorbackground

� Cost

� Community and staff acceptance


Level III* Inactivation of vegetative bacteria,fungi, lipophilic/hydrophilic viruses,parasites, and mycobacteria at a 6 log10

reduction or greater; and inactivationof B. stearothermophilus spores andB. subtilis spores at a 4 log10 reductionor greater;

Level IV Inactivation of vegetative bacteria,fungi, lipophilic/hydrophilic viruses,parasites, and mycobacteria, andB. stearothermophilus spores at a 6 log10

reduction or greater.

* Level III was selected as the recommended minimumcriteria by STAATT.

A 6 log10 reduction (or a 106 kill) is equivalent to aone millionth survival probability in a microbialpopulation or a 99.9999% reduction of the givenmicro-organism as a result of the treatmentprocess. Selected pathogen surrogatesrepresenting the above-mentioned micro-organisms are used in testing. The followingrepresentative biological indicators wererecommended at the second STAATT meeting(“ATCC” refers to the American Type CultureCollection).

ENVIRONMENTAL EMISSIONS AND WASTE RESIDUES

Facilities should consider discharges or emissions(including fugitive emissions) to all possibleenvironmental media – workplace air, outsideair, waste residues, wastewater, landfills, etc. –and select technologies with the least impact onthe environment. Facilities may be able to obtaindata from state regulators regarding any pastpermit violations by others using the technology.


Chapter 10

Economics of treatment technologies

CAPITAL COSTS

Total capital cost should include all direct andindirect costs related to siting and installation aswell as the equipment purchase cost. Sometechnologies require little site preparation andinstallation, while others involve significantinstallation requirements. The following list givesexamples of direct costs that need to be takeninto account. Not all of these items necessarilyapply to a given technology.

• Site preparation

• Demolition and disposal (e.g. removal of anold incinerator)

• Building (new construction or renovation)

• Foundation and supports

• Electrical service

• Piping including steam and water lines

• Heating and ventilation system

• Air compressor

• Lighting

• Sanitary sewer

• Sprinkler system

• Painting and insulation

• Handling and on-site fabrication

• Equipment purchase cost (includingauxiliary devices, instrumentation, carts fortransporting waste, monitoring equipment,freight, sales tax, etc.).

The following are examples of indirect costs thatshould be considered:

• Project management

• Engineering

• Construction fees

• Permitting

• Regulatory testing

• Professional fees (including media fees torespond to public outcry, if the communitydoes not like the technology choice)

• Start-up

• Performance testing

• Contingencies.

There are intangible costs, such as loss of goodpublic perception if the chosen technology isunpopular in the community or among staff thatcannot be quantified.

ANNUAL OPERATING COSTS

Annual operating costs are costs incurred everyyear due to the operation of the technologyduring the life of the equipment. Due to inflation,the magnitude of these costs may vary, but thesame kinds of costs will be incurred. Direct costsare those that are dependent on the throughputof the system, such as:

• Labour (operating and supervisory)

• Utilities

♦ Electricity

♦ Steam

♦ Natural gas

♦ Water

♦ Compressed air

♦ Others

• Supplies

♦ Boxes or containers

♦ Autoclavable or steam permeable bags

♦ Labels

♦ Others

• Consumables

♦ Chemical disinfectants

♦ Electrodes or torches

♦ Others

• Maintenance (scheduled and unscheduled)

♦ Materials

♦ Replacement parts (e.g, refractories,shredder blades, etc.)

♦ Maintenance labour

• Landfill disposal costs (includingtransportation and tipping fees)


• Cost of disposing wastes not treated by thetechnology

• Cost of treating waste during scheduled andunscheduled downtime.

Indirect costs are costs that are not proportionalto throughput, such as:

• Overhead

• Administrative costs

• Insurance

• Annual regulatory permit fees

• Periodic verification or emission tests

• Taxes.

INCINERATOR UPGRADE COSTS

With respect to incineration, cost is a major factorto consider in addition to the environmental,health, and other intangible issues raised inChapter 1. For an old existing incineratorcompliance with the new EU regulation formedical waste incinerators would likely requirethe installation of an expensive pollution controldevice, retrofit of the secondary chamber, and theaddition of monitoring equipment, as well asperiodic stack testing, operator training, etc.Therefore, capital cost items include:

• Purchase and installation of a wet scrubberor other device

• Secondary chamber retrofits

• Purchase and installation of monitoringequipment.

Components of annual operating costs include:

• Annual costs related to operation of a wetscrubber or other device

• Annual costs related to the secondarychamber

• Annual cost of stack testing

• Annual cost of parametric monitoring

• Annual cost of operator training course.


Appendix:

Non-incineration treatment technologies in Europe – case studies

The Centre Hospitalier in Roubaix, France

The capacity of the Centre Hospitalier in Roubaixis 2000 beds, with the production of 1 ton ofwaste (all types of waste) per bed annually. Thecomposition of the waste in the hospital isfollowing: Hazardous hospital waste - 15% (3% ofwhich are anatomical parts and cytostatics,the rest is infectious waste), the remaining 85% isnon-infection waste. This 85% is made up ofspecial industrial waste 2%, ordinary industrialwaste 3%, with the remaining 80% similar tohousehold waste of which 45% is recyclable.

Before 1993, the hospital in Roubaix incineratedits waste without much segregation in an on-siteincinerator. In 1993, they decided to shut downthe incinerator, and looked for other possibilitieshow to treat the waste. They chose to pre-sort wasteat the roots and to treat its infectious part on thespot, using a non-incineration method based on hotsteam. In August 1993, the hospital bought EcodasT1000 (a shredding-steam treatment-dryingtechnology), and in 1995 another T1000 unit.

According to the hospital, Ecodas units werechosen as it seemed to be the best adapted totheir needs: it’s environmentally friendly, itdecontaminates infectious waste using a steambased process at 138°C, and the internal shredderreduces the initial volume of waste by 80%.Collection and sorting waste on-the-spot wasadopted in virtue of the principle of proximity:less manipulation of infection risk waste productsimplies less professional risks for staff at thehospital, and for workers that collect waste.This also obviously reduces transport costs.

Mr. Bernard Poulain, the director of the hospital inRoubaix evaluates the switch from an incinerationto non-incineration method as follows:

“Our cost effective objectives have been met.

Our waste management is economical; we have

reduced the annual global cost of waste

management at the hospital by 30%. We have

improved risk control and we are more vigilant.

Our approach is also more ecological.”

Hospital waste management in Portugal

Until 1995, environmentally sound hospitalwaste management in Portugal was virtuallynon-existent. Legislation divided hospital wasteonly in two categories: Non hazardous waste,and hazardous waste. There was a very weaksource separation system and as a result 50% ofthe waste (25 000 t/year) was considered hazardous.The final destinations of the hazardous wastewere 40 on-site medical waste incinerators. Theenvironmental performance of these incineratorswas very poor. The combustion chambertemperature of most of them was below 800°C. Theydidn’t have any kind of flue gas treatment systems,and no air pollution monitoring was in place.

Due to the public pressure, in 1996 theGovernment approved a new legislation thatfinally allowed the autoclaving of infectiouswaste. In 1998 the Government approved theNational Plan for Hospital Waste with the targetof phasing out 30 existing incinerators, keepingonly one or two incinerators for the wholecountry in 2000. In 2003 and 2004 two of the lastthree medical waste incinerators were closed.The remaining facility is now under a lot ofpublic pressure to close because it doesn’t havean official permit to operate.

The amount of hazardous hospital waste hasbeen steadily decreasing since 1995 (25 000 tin 1995, 16 469 t in 2001, and 15 336 t in 2002)due to a better segregation of waste. Between1996 – 1998 two big autoclaves were built,which nowadays treat more than 80% of thetotal hospital hazardous waste produced inPortugal. With only one remaining medicalwaste incinerator, the incineration of hospitalwaste dropped dramatically from 25 000 t in1995, to 5726 t in 2001, and to 3174 t in 2002.

There is still room for further elimination ofincineration of hazardous hospital waste. Thelegislation from 1996 categorises medical wasteof group III and IV as hazardous. For category IVwaste incineration is compulsory (the category III


waste could be autoclaved), therefore the correctseparation of waste groups III and IV is essential.About 20% of hazardous hospital waste wasincinerated in 2002, but the amount of Group IVwaste represents only some 5% of the total wastein hospitals where a more serious segregationpolicy is in place (i.e. the District Hospital ofEvora or The Hospital Prelada in Porto).

Ireland has decided to treat hospital waste

by a non-incineration technology

Until recently, in Ireland approximately 50% ofhealthcare waste was incinerated on-site and 50%landfilled. With current trends both national andinternational there is considerable pressure onthe healthcare sector to shut down hospitalincinerators and find alternative ways of dealingwith wastes. At the present time, there are onlytwo hospitals with licensed incinerators, both ofwhich have not been in operation for the pastseveral years. It is anticipated that the last twomedical waste incinerators will be unlicensedand dismantled following the 150 otherincinerators that at one time existed in Ireland.

In a recent development, a joint Irish North/SouthBody, Joint Waste Management Board contractedSterile Technologies Ireland, a private wastemanagement company, for dealing with hospitalwaste in Ireland. Sterile Technologies Ireland use aSTI Model 2000 process in shredding waste priorto treatment followed by the injection of steamthat results in complete elimination of pathogenicmicro-organisms. Key parameters are continuouslymonitored and recorded providing for a safe,clean and accountable process of healthcare waste.The unrecognisable waste is held pendingverification and scientifically defined as sterilebefore sending to landfill.

The current position in Ireland is that 95% of allhealthcare waste treated on the island receivessegregation at source into specific disposal streamsof domestic and medical waste. The medical wasteis stored in wheeled bins at each hospital facilityand transported with electronic tracking from itspoint of production to its final disposal.

This way of dealing with medical waste changedthe perception that incineration was the only safemethod for healthcare waste disposal. A detailedexplanation of this new technology through

workshops helped the introduction of the systemto hospitals and aided segregation of waste atsource, dealing with the documentation,dedicated collection points and the wheeled binsused at each facility.

The waste, which is not acceptable using the STIModel 2000 process, falls under two categories.Firstly, packaging that is not sealed properly,which is damaged, holed or leaking andpackaging which does not have an identifiablecable tie attached and not labelled to denotesource and contents. This category if managed canchange and be processed. The second category iswaste that cannot be processed using the STIModel 2000 processing system. Cytotoxic, sharpand non-sharp waste, recognisable anatomicalwaste i.e. limbs, organs, waste containing CJD orHazard Group 4 pathogens, making approximately3% of the overall medical waste in Ireland isexported under transfrontier shipping licence toan incineration outlet in Belgium.

Slovenia has treated infectious waste using

hot steam mobile units since 1995

Until recently, according to the Slovenianregulation No. 1520 of 30/95 Collection of lawissued by Ministry of Health, all infectious wastehad to be dealt with the mobile equipmentZDA-M3 (mobile steam disinfection). There were3 mobile units in Slovenia, which treatedinfectious waste. The decontaminated waste wasconsequently landfilled. Incineration wasallowed only for other hazardous hospital wastecategories such as anatomical parts, cytostatics,and pharmaceuticals.

In November 2003 a new law, regulating hospitalwaste in Slovenia was adopted. This includesa new waste catalogue based on EU legislation.The previous regulation from 1995, which orderedthe use of non-incineration treatment technology,was cancelled resulting in both incineration andnon-incineration technologies being legal for thetreatment of infectious waste. At the momentinfectious waste still undergoes non-incinerationdecontamination processes, and hopefullySlovenia, as a new member of EU, will follow theexamples of its progressive EU neighbours andcontinue pursuing non-incineration technologiesfor the treatment of medical waste.

Health Care Without Harm Europe

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130 00 Prague, Czech Republic

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[email protected]

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